2019 ahs annual meeting - americanherniasociety.org · 8:15–8:30 introduction of the americas...

2019 AHS Annual Meeting

March 11–14, 2019, Las Vegas, NV

� Springer-Verlag France SAS, part of Springer Nature 2019

Monday, March 11, 2019

7:00–8:00 Registration & Breakfast

8:00–10:30 Session 1: Opening Session

Moderators: Gina Adrales, MD, MPH &

Benjamin Poulose, MD, MPH

8:00–8:10 Welcome and Opening Remarks


USA

8:15–8:30 Introduction of the Americas Hernia Society

World Partners

Gina Adrales, MD, MPH

USA

8:30–8:45 How Social Media Will Change Your Practice

and How to Get Ready

Brian Jacob, MD

USA

8:45–9:00 Robotics in Hernia Surgery: Stalling or Soaring?

Ajita Prabhu, MD

USA

9:00–9:15 Five Key Studies All Hernia Surgeons Should

Know

Sharon Bachman, MD

USA

9:15–9:45 Nyhus-Wantz Lecture

Sergio Roll, MD, PhD

Brazil

9:45–9:52 Safe Hernia Steps Program

Yuri Novitsky, MD

USA

9:52–10:00 Abdominal Core Health: The Time Has Come


USA

10:00–10:30 Presidential Address


USA

10:30–11:00 Break, Exhibits & Posters of Distinction

11:00–12:30 Session 2A: The Future Is Here: Robotics inHernia

Moderators: Yuri Novitsky, MD & Dana Telem,

MD

11:00–11:15 Evidence Update for Robotics: Where Do We

Need to Go?

Ajita Prabhu, MD

USA

11:15–11:30 Challenges of Starting a Robotic Program

Jaisa Olasky, MD

USA

11:30–11:45 Rethinking the Laparoscopic IPOM with

Robotics

Allegra Saving, MD

USA

11:45–12:00 From TEP to Robotic Inguinal Hernia Repair:

Why I Changed

David Lourie, MD

USA

12:00–12:15 Hernias, Residents and Robotics: Training the

Next Generation

Michael Meara, MD

USA

12:15–12:30 Robotic Retromuscular Abdominal Wall

Reconstruction

Igor Belyansky, MD

USA

11:00–12:30 Session 2B: Scientific Abstracts—InguinalHernia

Moderators: Diya Alaedeen, MD & Keith Paley,

MD

11:00–11:15 Closure of Direct Inguinal Hernia Defect in

Laparoscopic Hernioplasty to Prevent Seroma

Formation: A Prospective Double-Blind

Randomized Controlled Trial

Yilin Zhu, BS

China

PROGRAM

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Hernia (2019) 23 (Suppl 1):S1–S7

https://doi.org/10.1007/s10029-019-01889-w

https://doi.org/10.1007/s10029-019-01889-w

11:15–11:30 Hernia Recurrence Inventory: Inguinal Hernia

Recurrence Can Be Accurately Assessed Using

Patient-Reported Outcomes

Luciano Tastaldi, MD

USA

11:30–11:45 Method of Forming a Three-Layer Back Wall of

the Inguinal Canal and Complete Isolation of the

Spermatic Cord from the Mesh

Tamaz Gvenetadze, MD, PhD

Georgia

11:45–12:00 Preliminary Results at 3-Year Follow Up of

Totally Extraperitoneal Hernia Surgery with

Long-Term Resorbable Mesh

Fernando Ruiz-Jasbon, MD

Sweden

12:00–12:15 Phone Follow-Up After Inguinal Hernia Repair

Jacob Greenberg, MD, EdM

USA

12:30–1:30 Lunch & Learns

1:45–3:00 Session 3A: Avoiding and Managing ChronicGroin Pain After Inguinal Hernia Repair(Panel Session)

Moderators: David Chen, MD & David Krpata,

MD

1:45–2:00 Identifying Patients at Risk for Chronic Groin

Pain Before Operation

Rigoberto Alvarez, MD

Mexico

2:00–2:15 Strategies to Minimize Chronic Groin Pain in

Open and Minimally Invasive Inguinal Hernia

Repair

David Nguyen, MD

USA

2:15–2:30 Diagnosis and Management of Chronic Groin

Pain: An Overview

David Renton, MD

USA

2:30–2:45 Designing a Comprehensive Treatment Center

for Chronic Groin Pain

David Krpata, MD

USA

2:45–3:00 Panel Discussion

1:45–3:00 Session 3B: Scientific Abstracts—Robotics

Moderators: Conrad Ballecer, MD & Talar

Tejirian, MD

1:45–2:00 Automated Surgical Coaching for Technical

Skills Acquisition in Incisional Hernia Repair


USA

2:00–2:15 The Enhanced-View Totally Extraperitoneal

Robotic Rives-Stoppa Abdominal Wall

Reconstruction: A Review of Outcomes

Alex Addo, MD, MPH

USA

2:15–2:30 Robotic-Assisted Ipsilateral Rives Ventral Hernia

Repair vs. Open Rives Ventral Hernia Repair

Joshua Halka, MD

USA

2:30–2:45 Robotic Inguinal Hernia Repair is Being

Adopted by the Majority of Minimally Invasive

Hernia Surgeons

Priscilla Rodrigues Armijo, MD

USA

2:45–3:00 A Cost-Neutral Approach to Surgical Resident

Robotic Inguinal Hernia Training

Sarah Budney, BS

USA


3:30–5:30 Session 4A: Should We Be Gambling withOur Hernia Patients? Innovation with RiskSharing Is a Better Bet

AHS Special Session with the Kelley School ofBusinessModerators: Arachana Ramaswamy, MD & Paul

Szotek, MD

3:30–3:35 Introduction

Archana Ramaswamy, MD

USA

3:35–3:50 2018 Barracuda Tank Follow Up: Mesh Suture

(NON-CME)

Greg Dumanian, MD

USA

3:50–4:30 Overview of the US Healthcare System

Nir Menachmi, PhD, MPH

4:30–5:25 How Physicians Can Fix the System

Philip Powell, PhD

5:25–5:30 Closing Remarks

Paul Szotek, MD, MBA

3:35–3:50 2018 Barracuda Tank Follow Up: Mesh Suture

(NON-CME)

Greg Dumanian, MD

USA

3:30–5:30 Session 4B: Scientific Abstracts—VentralHernia

Moderators: Bryan Richmond, MD & Augustin

Alvarez, MD

3:30–3:45 Prehabilitation in Underserved, Minority

Patients With Ventral Hernias: Long-Term

Results of a Randomized Controlled Trial

Karla Bernardi, MD

USA

3:45–4:00 Comparative Efficacy of Transversus Abdominis

Plane Blocks and Epidural Catheters Following

Posterior Component Separation Hernia Repair

David Morrell, MD

USA

4:00–4:15 Repair of Complex Incisional Hernias After

Liver Transplant With TAR: The Experience

from Two Hernia Centers


USA

S2 Hernia (2019) 23 (Suppl 1):S1–S7

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4:15–4:30 Laparoscopic Ventral Hernia Repair: Results and

Challenges of Long-Term Follow-Up

Michael Lew, MD

USA

4:30–4:45 Lateral Abdominal Wall Hernias: A Single

Institution Review of 116 Consecutive Flank

and Lumbar Hernia Repairs

Kathryn Schlosser, MD

USA

4:45–5:00 Polylactide-Caprolactone Composite Mesh Used

for Ventral Hernia Repair: A Prospective,

Randomized, Single-Blind Controlled Trial

Yingmo Shen, MD

China

5:00–5:15 Nanoscience and Hernia Surgery: A Sexy Future

or a Dream That Will Never Come True?

Barbora East, MD, PhD

Czech Republic

5:15–5:30 Early Outcomes Following Use of Autologous

Fenestrated Cutis Grafts in Hernia Repair

Ian Hodgdon, MD

USA

5:30–7:00 Welcome Reception

Tuesday, March 12, 2019

7:00–8:00 Breakfast

8:00–10:30 Session 5: The Great Debate: Mesh,Litigation, Petrochemicals and the Patient(Panel Session)

Moderators: Michael Rosen, MD & Sharon

Bachman, MD

8:00–8:05 Introduction

8:05–8:20 Perceptions of Mesh Use in Hernia Repair

Shirin Towfigh, MD

USA

8:20–8:35 The Problem with Hernia Mesh—Perspective

from the Plaintiff’s Bar

Lisa Lee, JD

USA

8:35–8:50 Medicolegal Defense of Hernia Mesh Related

Lawsuits

Andrew Myers, JD

USA

8:50–9:05 What’s the Rate of Long Term Mesh Related

Complications in Ventral Hernia Repair?

Thue Bisgaard, MD

Denmark

9:05–9:20 Is It Acceptable to Use Petroleum-Derived

Meshes in Hernia Repair?

Mark Benvenuto, PhD

USA

9:20–9:35 Biologics and Bioabsorbable Meshes: Can We

Avoid the Issues with Synthetic Mesh in Ventral

Hernia Repair?

J. Scott Roth, MD

USA

9:35–9:50 #MeshIsBad—How Do We Talk to Patients?

B. Todd Heniford, MD

USA



11:00–12:30 Session 6A: The Changing Face of HerniaSurgery: Defining Who We Are (PanelSession)

Moderators: Vedra Augenstein, MD & Talar

Tejirian, MD

11:00–1105 Introduction

11:05–11:30 The Pathway to Equity: Intentional Steps to

Foster Diversity in Our Profession

Barbara Bass, MD

USA

11:30–11:45 Better Together: Reflections of the First Woman

Americas Hernia Society President


USA

11:45–12:00 Working Toward Gender Equality in Hernia

Surgery: The Role of Men

Jeffrey Janis, MD

USA

12:00–12:15 South American Perspective on Diversity

Among Hernia Surgeons

Evelyn Dorado, MD

Colombia


11:00–12:30 Session 6B: Scientific Abstracts—AbdominalWall Reconstruction

Moderators: Sean Orenstein, MD & John

Fischer, MD

11:00–11:15 Current Trends and Practices in Complex

Abdominal Wall Reconstruction: Results of a

Physician Survery

Dina Podolsky, MD

USA

11:15–11:30 Appreciation of Post Partum Changes of the

Rectus Muscles in Primary and Re-Do

Abdominoplasty

Lindsay Janes, MD

USA

11:30–11:45 The Incremental Impact of Obesity and Smoking

on Surgical Site Infections After Complex

Abdominal Wall Reconstruction

Andrew Shover, MD

USA

11:45–12:00 The Impact of Inadvertent Enterotomy During

Open Abdominal Wall Reconstruction (AWR)

Angela Kao, MD

USA

12:00–12:15 Does Loss of Domain Impact Outcomes for

Abdominal Wall Reconstruction Procedures?

Miles Landry, MBBS

USA

12:15–12:30 Hybrid vs. Open Abdominal Wall Reconstruction:

Early Outcomes

Alex Addo, MD, MPH USA


Hernia (2019) 23 (Suppl 1):S1–S7 S3

123

1:45–3:45 Session 7A: AHS Safe Hernia Steps—Technical Tips for Common Problems inYour Hernia Practice

Moderators: Yuri Novitsky, MD & Lucas Beffa,

MD

1:45–2:00 Open Repair for Smaller Ventral Hernias:

Evidence Based Decisions

Susanne van der Velde, MD, PhD

Netherlands

2:00–2:15 Open Rives-Stoppa Ventral Hernia Repair

Wolfgang Reinpold, MD, PhD

Germany

2:15–2:30 Laparoscopic IPOM

Bernd Stechemesser, MD

Germany

2:30–2:45 Open Inguinal Hernia Repair: Tissue Based

Approach

John Morrison, MD

Canada

2:45–3:00 Open Inguinal Hernia Repair: Mesh Based

Approach

David Chen, MD

USA

3:00–3:15 Laparoscopic Inguinal Hernia Repair: The

Critical View

Edward Felix, MD

USA

3:15–3:30 Strategies for Success in Parastomal Hernia

Repair

Sharon Bachman, MD

USA

3:30–3:45 Incorporating Robotics into Your Hernia

Practice: Starting with the Right Procedures

Conrad Ballecer, MD

USA

1:45–3:45 Session 7B: Video and Special AwardAbstracts

Moderators: Kamal Itani, MD & Flavio Malcher

de Oliveira, MD

1:45–2:00 Females in Hernia Surgery Scholarship: Gender-

Specific Outcomes After Open Hernia Repair

(OVHR)


USA

2:00–2:15 Diversity in Healthcare Delivery Grant:

Socioeconomic Disparity Exists Among Those

Undergoing Emergent Hernia Repairs in the

State of New York

Salvatore Docimo, Jr., DO, MS

USA

2:15–2:30 AHSQC Resident Research Grant: Registry-

Based, Randomized Controlled Trial

Comparing Intra-Operative Foley Catheter vs.

No Catheter for Minimally Invasive Inguinal

Hernia Repair

Aldo Fafaj, MD

USA

2:30–2:45 AHSQC Resident Research Grant: Perioperative

Analgesia with Transversus Abdominis Plane

(TAP) Block vs. Epidural Analgesia: Analysis

from the Americas Hernia Society Quality

Collaborative

Ibnalwalid Saad, MD

USA

2:45–3:00 Re-Do TAR


USA

3:00–3:15 Panniculectomy, Perioperative Botulinum-Toxin

A and Preperitoneal Ventral Hernia Repair in a

Morbidly Obese Patient with Loss of Domain

Sean Maloney, MD

USA

3:15–3:30 Single Incisional Laparoscopic TEP Hernia

Repair Under Local Anesthesia

Norihito Wada, MD, PhD

Japan


4:15–5:30 Session 8A: Hot Topics in ComplexAbdominal Wall Reconstruction

Moderators: Vedra Augenstein, MD & Eric

Pauli, MD, MBA

4:15–4:30 Chemical Component Separation: Practical Use

and Review of the Data

B. Todd Heniford, MD

USA

4:30–4:45 Why Retromuscular? Onlay Can Do the Job

David Webb, MD

USA

4:45–5:00 Performing Posterior Component Separation

(TAR) Correctly

Yuri Novitsky, MD

USA

5:00–5:15 Myofascial Release After Previous Abdominal

Wall Reconstruction

Jeremy Warren, MD

USA

5:15–5:30 Five Plastic Surgery Tips All Hernia Surgeons

Should Know

Jeffrey Janis, MD

USA

4:15–5:30 Session 8B: Scientific Abstracts—VentralHernia IIModerators: Dmitry Oleynikov, MD & Paul

Szotek MD, MBA

4:15–4:30 Prevention of Incisional Hernia with Cutis

Autograft Augmentation

Aran Yoo, MD

USA

4:30–4:45 Computed Tomography Imaging in Ventral

Hernia Repair: Can We Predict the Need for

Myofascial Release?

Wes Love, MD

USA

4:45–5:00 The Impact of Weight Change on Intra-

Abdominal and Hernia Volumes


USA

5:00–5:15 Characterization of Information on Surgical

Mesh for Hernia Repair on the Internet

Matthew Miller

USA


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Wednesday, March 13, 2019


8:00–10:30 Session 9: Special Problems in AbdominalCore Health

Moderators: Richard Pierce, MD, PhD &

Rebecca Petersen, MD

8:00–8:15 The Diastasis Recti Problem: Are There

Solutions That Work?

Salvador Morales-Conde, MD

Spain

8:15–8:30 Femoral Hernia Repair: Practical Tips

Matthew Goldblatt, MD

USA

8:30–8:45 Decision Making in Core Muscle Injury/Sports

Hernia

Giampiero Campanelli, MD

Italy

8:45–9:00 Reimbursement for Hernia Prophylaxis: Myth

and Reality

John Fischer, MD, MPH

USA

9:00–9:15 My Patient Has a Mesh Infection: Now What?

Pilar Hernandez-Granados, MD

Spain

9:15–9:30 Ventral Hernia Management in the Morbidly

Obese Patient

Rana Higgins, MD

USA

9:30–9:45 Fight or Flight? Ventral Hernia in the Emergent

Setting

Salvatore Docimo, Jr., DO, MS

USA

9:45–10:00 Laparoscopic Hiatal Hernia Repair: Keys to

Success

Kyle Perry, MD

USA

10:00–10:15 Complex Hiatal Hernia: When to Involve Your

Thoracic Surgeon Up Front

Aaron Bolduc, MD

USA

10:15–10:30 To Mesh or Not to Mesh: Prosthetic Use in

Hiatal Hernia Repair

Rebecca Petersen, MD

USA


11:00–12:30 Session 10A: WWYD (What Would You Do?)from International Hernia Collaboration toAmericas Hernia Society

Moderators: Brian Jacob, MD & Sarah

Bryczkowski, MD

11:00–11:10 Complication After an Open Transversus

Abdominus Release

Andrea Pakula, MD, MPH

USA

11:10–11:20 Incisional Hernia and Diastasis: From the IHC

Archives

David Santos, MD

USA

11:20–11:30 Totally Robotic Parastomal Repair With End

Ileostomy Reversal

Sarah Bryczkowski, MD

USA

11:30–11:45 Robotic Tapp Inguinal Hernia Repair Complicated

By Postoperative Small Bowel Obstruction

Stephen Pereira, MD

USA

11:45–12:00 Chronic Small Bowel Obstruction After IPOM

Lucian Panait, MD

USA

12:00 -12:10 Hernia and Diastasis: How I Do It

Mario Leyba, MD

USA

12:10–12:20 Complication During Open AWR: Divided

Linea Semilunaris

Joseph DeVitis, MD

USA

12:20–12:30 Mystery Finding Prior to Hernia Surgery

Adam Rosenstock, MD

USA

11:00–12:30 Session 10B: Hernia Care in ChallengingScenarios (Panel Session)

Moderators: Jeffrey Blatnik, MD & Shirin

Towfigh, MD

11:00–11:15 Many Hernias, Few Resources…and No Robots!

Charles Filipi, MD

USA

11:15–11:30 How We Approach Hernia Repair in a Tent in

the Amazon

Claudia Lorenzetti, MD

Brazil

11:30–11:45 Managing the Abdominal Wall and Hernias in

the Military

Eric Johnson, MD

USA

11:45–12:00 Training and Capacity Building in Rwanda

Ralph Lorenz, MD

Germany

12:00–12:15 Hernia Decision Making in the Non-Verbal

Patient

Salvatore Docimo, Jr., MD, MS

USA



1:45–3:15 Session 11A: Hernia Prophylaxis—AHS Stopthe Bulge Campaign (Panel Session)

Moderators: Hobart Harris, MD & Dana Telem,

MD

1:45–2:00 Abdominal Wall Closure: European Hernia

Society Guidelines

Filip Muysoms, MD

Belgium

2:00–2:15 What’s the Matter America? Why Not More

Small Bites and Prophylactic Mesh?

Johannes Jeekel, MD

Netherlands

2:15–2:30 Parastomal Hernia Prevention: Do We Have a

Consensus?

Agneta Montgomery, MD

Sweden

2:30–2:45 Why Hernia Prevention Makes Sense

Hobart Harris, MD, MPH

USA


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2:45–3:00 Small Bites Versus Prophylactic Mesh: Which to

Use When?

Rene Fortelny, MD

Austria


1:45–3:15 Session 11B: Scientific Abstracts—Hot Topicsin Hernia

Moderators: Vimal Narula, MD & Claudia

Lorenzetti, MD

1:45–2:00 A New Technique for Peritoneal Flap Closure In

TAPP: A Prospective Randomized Controlled

Trial

Yilin Zhu, BS

China

2:00–2:15 Is the International Hernia Collaboration a Safe

and Effective Resource for Surgeons?

Karla Bernardi, MD

USA

2:15–2:30 Mesh Suture Better Resists Suture Pull-Through

Than Small Bites Surgical Technique

Jason Souza, MD

USA

2:30–2:45 Experience with the Pinq-Phone Telephone

Questionnare for Detection of Recurrences

After Endoscopic Inguinal Hernia Repair

Wouter Bakker, MD

Netherlands

2:45–3:00 A Role for the Integrin Subunit Beta 1 Gene in

Direct Inguinal Hernia with Family History

Lei Zhu, MD

China

3:00–3:15 Management of Abdominal Wall Hernias in

Women of Childbearing Age: A Qualitative

Study Assessing Surgeon Practice

Sara Jafri

USA

3:15–3:30 Prevalence of Posttraumatic Stress Disorder

(PTSD) in Patients with an Incisional Hernia

Hemasat Alkhatib, MD

USA


4:15–5:30 Session 12A: AHSQC Panel Session: LongTerm Follow Up and Registry-Based ClinicalTrials

Moderators: Benjamin Poulose, MD, MPH &

Michael Rosen, MD

4:15–4:30 Hybrid Robotic Transversus Abdominus Release

Has Shorter Length of Stay Compared to Open

Transversus Abdominis Release: An AHSQC

Analysis

Alexander DeMare, MD

USA

4:30–4:45 Is Mechanical Fixation Needed in Open

Retromuscular Ventral Hernia Repair?

Richard Pierce, MD

USA

4:45–5:00 Telescopic Dissection vs. Balloon Dissection in

Laparoscopic TEP Repair: A Registry-Based

Randomized Controlled Trial


5:00–5:15 Assessing Outcomes of Myofascial Release

Using the AHSQC

Paul Tenzel, MD

USA

5:15–5:30 Integration and Implementation of Patient

Recorded Outcomes (PROs) into Clinical

Practice

Shelby Nathan, MD

USA

4:15–5:30 Session 12B: Scientific Abstracts—ParastomalHernia & Hiatal Hernia

Moderators: Kyle Perry, MD & Kristi Harold,

MD

4:15–4:30 Hiatal Hernia and Gerd: An Indication for

Conversion from Sleeve Gastrectomy to Rous-

En-Y Gastric Bypass

Raelina Howell, MD

USA

4:30–4:45 Prophylactic Mesh Augmentation for Prevention

of Parastomal Hernia

Allison Foster, BS

USA

4:45–5:00 A Retrospective Review with Prospective

Follow-Up of 85 Consecutive Patients Treated

with Miromesh� for Hiatal Hernia Repair

G. Kevin Gillian, MD

USA

5:00–5:15 Large Hiatal Hernia with the Upside-Down

Stomach. What Is the Best Way?

Pavol Klobusicky, MD

Germany

5:15–5:30 Mesh Salvage Following Deep Surgical Site

Infection

Stephen Siegal, MD

USA

Thursday, March 14, 2019


8:00–10:00 Session 13: Spectacular Cases (Panel Session)

Moderators: Eric Pauli, MD, Elizabeth Colsen,

MD, Clayton Petro, MD & Paul Colavita, MD

8:00–8:05 Inroduction

Paul Colavita, MD

8:05–8:20 Chronic Groin Pain Leading a 22-Year Old to

Disability. What Now?

Paulo Henrique Fogaca de Barros, MD

Brazil

8:20–8:35 Lateral Abdominal Wall Dehiscence After

Component Separation

Joseph DeVitis, MD

USA

8:35–8:50 Robotic TAPP Inguinal Hernia Repair: A

Palliative Approach in a Patient with Sepsis

and Possible Penumatosis Intestinalis

Osvaldo Zumba, MD

USA

8:50–9:05 Repair of Spontaneous Intercostal Hernia aia

Open Transthoracic Extrapleural Approach


USA


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9:05–9:20 Abdominal Wall Reconstruciton in a Patient

with an Incomplete Anterior Pelvic Ring

Aldo Fafaj, MD

USA

9:20–9:35 Just Your ‘‘Routine’’ Open Inguinal Hernia

Repair

Sean Maloney, MD

USA


10:00–10:30 Break

10:30–12:30 Session 14: Special Technique in Ventral andInguinal Hernia

Moderators: Jacob Greenberg, MD, EdM &

Sergio Roll, MD

10:30–10:45 The Laparoscopic Onlay Repair: Why You

Should Consider It

Leandro Totti Cavazzola, MD

Brazil

10:45–11:00 Minimally Open Sublay Technique (MILOS)

Wolfgang Reinpold, MD

Germany

11:00–11:15 A Successful Approach to Managing

Enterocutaneous Fistula

Kristi Harold, MD

USA

11:15–11:30 Extraperitoneal Minimally Invasive Repair

Options

Christiano Claus, MD, PhD

Brazil

11:30–11:45 A New Approach to Laparoscopic Bilateral

Inguinal Hernia Repair: The BTOM

Gustavo Castagneto, MD

Argentina

11:45–12:00 Intraperitoneal Polypropylene in Giant Ventral

Hernia

Claudio Brandi, MD

Closing Remarks

12:00–12:15 Meeting Award Presentations


USA

12:15–12:30 Transition of Presidency/Closing Remarks


USA

12:30 Adjourn


123


Session 1: Opening Session


IP-1299

How Social Media Will Change Your Practice and How

to Get Ready

Jacob BLaparoscopic Surgical Center of New York

.

IP-1300

Robotics in hernia surgery: stalling or soaring?

Prabhu ACleveland Clinic

.

IP-1301

Five key studies all hernia surgeons should know

Bachman SInova

.

IP-1302

Nyhus-Wantz lecture

Roll SSao Paulo, Brazil

.

IP-1303

Safe hernia steps program

Novitsky YColumbia

.

IP-1304

Abdominal core health: the time has come

Poulose BThe Ohio State University Wexner Medical Center

.

IP-1305

Presidential address

Adrales GJohns Hopkins

.

ABSTRACTS

123

Hernia (2019) 23 (Suppl 1):S8


Session 2A: The Future Is Here: Robotics in Hernia


IP-1306

Evidence update for robotics: where do we need to go?

Prabhu ACleveland Clinic

.

IP-1287

The challenges of starting a robotic program

Olasky JMount Auburn Hospital

Building a robotic surgery practice can be a slow process with many

unique challenges including financial concerns, credentialing issues,

and staffing problems. These obstacles depend in part on the climate

of the institution involved. This talk will cover the most common

barriers to building a robotic hernia program and present strategies for

overcoming them.

IP-1291

Rethinking the laparoscopic IPOM with robotics

Saving ANorton Surgical Specialists/Louisville General Surgery

The laparoscopic IPOM is where minimally invasive ventral hernia

repair got its start in the early 1990s. Compared to open repair, it

allowed for minimal incisions, quicker surgery time and recovery, and

decreased wound morbidity. However, issues including poor or no

defect closure, post-operative pain, and complications from

intraperitoneal mesh placement brought criticism. These critiques

coupled with further advancements in abdominal wall reconstruction

caused it to fall a bit out of favor. With the advent of robotic tech-

nology, some of the technical concerns have now been sorted out.

Robotics has begun restoring the MIS intraperitoneal mesh onlay

technique as a useful approach for hernia repair. In particular, this

procedure arguably may be the most suitable method for certain select

patient groups. Therefore, robotic-assisted laparoscopic IPOM should

be restored as one of the many skills a comprehensive hernia surgeon

should utilize.

IP-1289

From TEP to robotic inguinal hernia repair: why I

changed

Lourie DHuntington Hospital

I could do a 20 min laparoscopic TEP inguinal hernia repair with my

eyes closed (or at least my lens blurred). After thousands of cases,

with great outcomes, why in the world would I ever want to start over

and change? Well, have a seat (at the robotic console) and let me tell

you why now I cannot imagine going back.

IP-1307

Hernias, residents, and robotics: training

the next generation

Meara M.

IP-1308

Robotic retromuscular abdominal wall reconstruction

Belyansky IAnne Arundel Medical Center

ABSTRACTS

123



Session 2B: Scientific Abstracts—Inguinal Hernia


FP-1156

Closure of direct inguinal hernia defect in laparoscopic

hernioplasty to prevent seroma formation:

a prospective double-blind randomized controlled trial

Zhu Y, Wang MBeijing Chao-Yang Hospital

Objectives: Seroma is the most frequent postoperative complication

after laparoscopic direct inguinal hernia repair. This randomized

controlled trial evaluated the preventive effect of a simple technique

by closing the direct hernia defect with barbed suture in laparoscopic

direct inguinal hernia.

Methods: 60 patients aged 18 years or older who presented to the

hernia center department in our hospital between October 1, 2017 and

January 1, 2018 with primary direct inguinal hernia were randomized

into the defect-closing group and the control groups. The primary

outcomes were to compare the ultrasonic seroma number and volume

at the inguinal region at 7 days, 1 month and 3 months postopera-

tively. Secondary outcomes included total operative time, acute pain,

chronic pain (pain lasting over 3 months), hospital stay, recurrence

and any other complications.

Results: There were no significant differences in baseline demo-

graphic characteristics between the two groups including age, sex,

hernia type, size of hernia defect, surgical approach and follow-up

time. Compared with control group, there were significantly fewer

patients with seroma formation at 7 days, 1 month and 3 months after

the operations in the defect-closing group (p\ 0.001, p\ 0.001,

p = 0.002, respectively). In addition, ultrasonic seroma volume was

less in the defect-closing group on postoperative day 7 (13.33 ml vs.

30.45 ml, p = 0.02). The acute pain and hospital stay were compa-

rable (p = 0.61, p = 0.85, respectively), and no chronic pain, early

recurrence or other postoperative complications observed in both

groups during the follow-up period.

Conclusions: The simple technique of direct hernia defect closure

with barbed suture in laparoscopic direct inguinal hernia repair is a

secure and effective method, which is easy to perform and could

significantly reduce both incidence and volume of seroma formation

without increasing the risk of recurrence, acute and chronic pain.

FP-1244

Hernia recurrence inventory: inguinal hernia

recurrence can be accurately assessed using patient-

reported outcomes

Tastaldi L, Barros P, Krpata D, Prabhu A, Rosenblatt S,

Altenfelder Silva R, Roll S, Rosen M, Poulose BCleveland Clinic

Background: We aim to determine if inguinal hernia recurrences

could be assessed using the Ventral Hernia Recurrence Inventory

(VHRI), a previously existing patient-reported outcome (PRO) tool

which has already been validated for diagnosing ventral hernia

recurrence.

Methods: Adult patients from two centers (United States and Brazil)

at least 1 year after inguinal hernia repair were asked to prospectively

answer the questions of the VHRI in relation to their prior repair. A

physical exam was then performed by a blinded surgeon, and testing

characteristics were calculated.

Results: 128 patients were enrolled after 175 repairs. All patients

answered the VHRI and were further examined, where a true recur-

rence was present in 32% of the repairs. Self-reported bulge and

patient perception of a recurrence were highly sensitive (83%–93%)

and specific (82%–94%) for the diagnosis of an inguinal hernia

recurrence. Test performance was similar in the American and

Brazilian populations despite several baseline differences in demo-

graphic and clinical characteristics.

Conclusion: The VHRI can be used to assess long-term inguinal

hernia recurrence and should be reestablished as the Hernia Recur-

rence Inventory (HRI). Its implementation in registries, quality

improvement efforts, and research could contribute to improving

long-term follow-up rates in hernia patients.

FP-1118

Method of forming a three-layer back wall

of the inguinal canal and complete isolation

of the spermatic cord from the mesh

Gvenetadze TGudushauri National Medical Center, David Agmashenebeli

University of Georgia

Objectives: The study and comparison of quantitative composition of

spermatozoids prior and after Lichtenstein and Gvenetadze methods.

Materials and methods: For the recent 10 years 1200 patients have

been operated on by the isolation method. 215 patients of the repro-

ductive age (19–40 years.) with the bilateral inguinal hernias became

ABSTRACTS

123

Hernia (2019) 23 (Suppl 1):S10–S11

the object of study. The patients were allocated into two groups. The

first group contained those 66 patients (30.7%) who underwent

bilateral Lichtenshtein hernia repair. The second group—149 patients

(69.3%) on whom bilateral hernia repairs by Gvenetadze method have

been utilized. Complete spermomorphocitological investigations have

been performed in all groups 2 days prior to surgery, 30 days and

6 months after surgery.

Results: Oligospermia, reduction of the quantitative sperm compo-

sition by 30–35% was revealed only in the first group (p\ 0.01). In

the second group no significant differences was registered. 68 patients

had children after surgery by Gvenetadze method.

Conclusion: Hernioplasty by Gvenetadze prevents male infertility in

all cases especially for bilateral inguinal hernia repair as well as in

reproductive age. The given technique is more solid as the posterior

wall of the inguinal canal presented by the transverse fascia, mesh and

aponeurosis of the external oblique muscle therefore the recurrence

rates of hernia is minimized and practically excluded. Based on the

foregoing results this method is considered as an effective method of

hernioplasty as for young as well for elderly patients.

FP-1093

Preliminary results At 3-year follow up of totally

extraperitoneal hernia surgery with long-term

resorbable mesh

Ruiz-Jasbon F, Ticehurst K, Ahonen J, Norrby J, Ivarsson

MHalland’s Hospital/Kungsbacka

Introduction: Synthetic non-resorbable mesh is almost standard in

hernia surgery nowadays. However several studies have showed

negative effects of permanent implants such as chronic inflammation

and complications involving different organs bordering the mesh.

Moreover promising results regarding pain in patients with lateral

inguinal hernia (LIH) has been published using a slowly resorbable

mesh in Lichtenstein technique. For this reason the aim of the present

study was to find the rate of hernia recurrence and chronic post-

operative pain long-term in patients with LIH repaired with slowly

resorbable implant in TEP procedure.

Methods: Pilot prospective study of TEP repair using TIGR� Matrix

Surgical Mesh in 35 primary LIH. Visual Analogue Scale (VAS) and

Inguinal Pain Questionnaire (IPQ) were employed to assess pain.

Recurrence was determined by ultrasound and clinical examination.

Results: No patients had chronic pain, as defined in the World

Guidelines for Groin Hernia Management, or recurrence at one-year

follow up. 3-year follow up results will be presented at the AHS 2019

Annual Meeting.

FP-1064

Phone follow-up after inguinal hernia repair

Greenberg J, Liu N, Xu Y, Altimari M, Shada A, Funk L,

Lidor AUniversity of Wisconsin

Background: Inguinal hernia repair (IHR) is one of the most com-

monly performed procedures in the United States. With a low rate of

complications and a relatively brief recovery period, many patients

have already returned to work and normal activities by the time of

their postoperative visit. We hypothesized that a phone follow-up

protocol could safely be utilized following IHR.

Methods: Adult patients (age C 18) who underwent elective outpa-

tient IHR at a single institution academic center during 2013–2016

were retrospectively identified from the electronic medical record

(EMR). Phone follow-up patients were contacted by phone 1–2 weeks

following surgery and asked a specific set of questions which were

entered into the EMR. Patients’ baseline characteristics, perioperative

course, and follow-up information were collected from the EMR.

Predictors of surgery outcomes including related 90-day ED visits,

readmissions and reoperations were analyzed using an intention-to-

treat comparing those who received phone follow-up versus in-person

follow-up. Multivariable logistic regression analysis for the outcomes

of interest was performed.

Results: 1039 patients underwent IHR during the study period. 754

were performed via a laparoscopic approach (338 TAPP vs. 416

TEP), while 244 were performed open. 261 patients had bilateral

hernias, while 52 had recurrent hernias. 786 had phone follow-up, and

220 had in-person follow-up only. Baseline demographics and oper-

ative approach were similar between the two groups. The composite

rate of ER visits/readmissions/reoperations within 90 days of surgery

was similar between the phone follow-up and in person groups

(9.80% vs. 7.27%, p = 0.253). Multivariable logistic regression

demonstrated that the odds of having related ER visit/readmission/

reoperation was similar between the two groups.

Conclusion: Patients who underwent phone follow-up had similarly

low rates of adverse outcomes compared to those with in-person

follow-up after inguinal hernia repair. Phone follow-up protocols may

be implemented as a means to decrease healthcare utilization fol-

lowing IHR.

123

S11 Hernia (2019) 23 (Suppl 1):S10–S11


Session 3A: Avoiding and Managing Chronic Groin Pain After Inguinal Hernia Repair(Panel Session)


IP-1309

Identifying patients at risk for chronic groin pain

before operation

Alvarez RJalisco, Mexico

.

IP-1310

Strategies to minimize chronic groin pain in open

and minimally invasive inguinal hernia repair

Nguyen D.

IP-1312

Diagnosis and management of chronic groin pain:

an overview

Renton DThe Ohio State University Medical Center

.

IP-1313

Designing a comprehensive treatment center

for chronic groin pain

Krpata DCleveland Clinic

ABSTRACTS

123



Session 3B: Scientific Abstracts—Robotics


IP-1315

Automated surgical coaching for technical skills

acquisition in incisional hernia repair


.

FP-1226

The enhanced-view totally extraperitoneal robotic

Rives-Stoppa abdominal wall reconstruction: a review

of outcomes

Addo A, Parlacoski S, Broda A, Zahiri R, Lu R, Turcotte J,


Background: We recently reported 30-day outcomes post enhanced-

view totally extraperitoneal (eTEP) robotic Rives-Stoppa abdominal

wall reconstruction (AWR). This novel minimally invasive approach

allows repair of complex ventral hernias, correction of midline con-

tour abnormalities and restoration of the linea alba. It also allows

wide mesh overlap while avoiding invasive fixation and mesh contact

with intraperitoneal viscera. This study reports our outcomes beyond

the initial 30 days.

Methods: We conducted a retrospective review of all patients who

underwent eTEP robotic Rives-Stoppa AWR between June of 2017

and May of 2018 at Anne Arundel Medical Center. Patient demo-

graphics and perioperative data were evaluated using univariate

analysis.

Results: Ninety-two patients were included for this analysis. Patients

consisted of 52% female and 48% male. Mean age, BMI and median

ASA score were 51 years, 34.15 kg/m2 and 2 respectively. Intraop-

erative data analysis revealed mean operative time of 182.9 min.

Mean area of implanted mesh was 510 cm2. In 22 percent of cases,

drains were placed above the mesh in the retrorectus space and

removed on average 5 days after surgery. The mean length of stay

was 0.4 days as most patients were same day discharge. Average

length of follow-up was 3.6 months. During this time, two patients

developed posterior rectus sheath failure with incarceration of small

bowel requiring emergent exploration, bowel resection and abdominal

wall reconstruction with transversus abdominis release. One patient

had a recurrence within 1 year following surgery.

Conclusion: The eTEP Robotic Rives-Stoppa AWR offers a com-

prehensive approach to the restoration of abdominal wall anatomy in

the least invasive fashion. While outcomes indicate it is both safe and

effective with enhanced recovery for patients, further long-term fol-

low-up is required to better characterize unique complications such as

posterior rectus sheath failure, as well as, long-term recurrence rates.

FP-1171

Robotic-assisted ipsilateral rives ventral hernia repair

versus open rives ventral hernia repair

Halka J, Demare A, Vasyluk A, Iacco A, Janczyk RWilliam Beaumont Hospital

Background: Robotic assisted surgery allows for complex abdominal

wall dissections, such as the Rives retrorectus repair, to be performed

in a minimally invasive manner. Although robotic assistance may

offer distinct advantages, there are potential pitfalls when compared

to the open operation. We describe our initial experience with the

ipsilateral robotic retrorectus repair compared to open for moderate

size ventral hernias.

Methods: Data for all Rives retrorectus hernia repairs performed at

our institution between 2014 and 2017 were gathered from our

institutional database along with the Americas Hernia Society Quality

Collaborative (AHSQC). Patient demographics, operative details, and

short term outcomes data were analyzed.

Results: 121 open patients and 45 robotic assisted hernia repair

patients were analyzed. Patient populations were statistically similar.

Length of stay was significantly shorter in the robotic group (1 day vs.

3 days, p = 0.02). Readmissions, SSO requiring intervention were

statistically similar between groups. While not statistically significant,

readmissions were higher in the robotic group (4% vs. 10% p = 0.23)

and reoperations were higher in the robotic group (3% vs 10%

p = 0.11). The open group had four re-operations, one for posterior

flap disruption and resultant SBO, one for seroma drainage, and two

for hematoma drainage. The robotic group had four re-operations, two

due to SBO from peritoneal flap disruption, one for hematoma

evacuation, and one for abscess drainage. Half of the reoperations in

the robotic group were for SBO secondary to posterior flap disruption.

Seromas were higher in the robotic group (12% vs 6%), but were not

statistically significant.

Conclusion: While robotic-assisted ipsilateral Rives ventral

retrorectus hernia repair may offer advantages compared to the open

procedure, surgeons should be aware of the potential risks involved

with this choice in operation as shown in our initial experience.

ABSTRACTS

123

Hernia (2019) 23 (Suppl 1):S13–S14

FP-1130

Robotic inguinal hernia repair is being adopted

by the majority of minimally invasive hernia surgeons

Rodrigues Armijo P, Oleynikov DUniversity of Nebraska Medical Center

Introduction: Little is known about how robot technology is

employed by minimally invasive general surgeons. Our aim was to

evaluate the needs of established robotic surgeons and of those who

are new to this technology.

Methods: A survey was designed and sent electronically to all

SAGES members. Questions included fellowship training, area of

expertise, robotic simulation and in clinical case use, services offered

in the current hospital, mentorship, likelihood of switching to a dif-

ferent approach, and expectations for the robot. Descriptive analysis

were conducted using STATA/MP 15.1.

Results: Of all survey respondents, 189 self-identified as hernia

surgeons. Among those hernia surgeons, 73.8% had additional fel-

lowship, with majority practicing for 3–6 years (54%). Nearly 40% of

interviewees were MIS surgeons (N = 73), followed by general sur-

gery (34.4%), and bariatrics (13.8%). Surprisingly, 146 respondents

(77.7%) had used the daVinci� in a clinical setting. Among robotic

surgeons, majority is performing less than 10 cases per month using

robotic-assistance. Inguinal hernia repairs are the leading procedures

among those (49%), followed by foregut-related (19.5%), and col-

orectal-related surgeries (17.5%). Nearly 40% of surgeons stated

inguinal hernia repairs to the most often performed procedure using

the robot. Interestingly, 42.5% of hernia surgeons are planning to

switch from open procedures to its robot counterpart, whereas 39.4%

are planning to adopt robotic-assisted procedures rather than laparo-

scopy. Level 1 evidence (47.9%) and cost (24.1%) were the most

pressing needs for robotic research.

Conclusions: Majority of survey respondents have used the daVinci�

in a clinical setting. While robotic cases represent only a portion of

the surgeries performed, inguinal hernia repairs and foregut appear to

be the most common procedures done with robotic-assistance. This

data shows that nearly half of hernia surgeons will be adopting robotic

technology over its open or laparoscopic counterparts.

FP-1191

A cost-neutral approach to surgical resident robotic

inguinal hernia training

Budney S, Richards J, Rubalcava N, Israr S, Weinberg J,

Gagliano R, Gillespie TCreighton University and Medical Center at St. Joseph Hospital

and Medical Center

Introduction: The adoption of robotic surgery has been expensive

and time consuming; however, residency programs are responsible for

training residents in technologies that will be part of their scope of

practice. The lean start-up methodology is a set of operating princi-

ples designed to expedite the research and development phase of

production. Through iterative product releases, producers cycle

through building, measuring, and learning to create a final product. A

well-trained general surgeon applied the lean start-up methodology to

his surgical practice and is now able to perform R-TAPP IHR at an

equivalent or lower cost than L-TEP. Here we examined if applying

lean start-up methodology in training surgical residents has similar

results.

Methods: We completed a retrospective and prospective cost com-

parison analysis of a single surgical educator’s ‘‘last 12 taught’’

L-TEPs (Group A), ‘‘first 12 taught’’ R-TAPPs (Group B), and ‘‘last

12 taught’’ R-TAPPs (Group C). All R-TAPP procedures were per-

formed using lean start-up principles. We performed small batch

analysis of total consumable material cost, including cost of mesh and

‘‘per use’’ cost of robotic instruments. Statistical analysis was per-

formed using one-way ANOVA with post hoc Bonferroni correction.

Statistical significance was defined as p\ 0.05. We determined a line

of best fit for R-TAPP cost versus case number to calculate the case

number when R-TAPP training becomes cost-neutral to L-TEP.

Results: The average cost for Group B was $1867.05 and $207.24

more expensive than Group A. The average cost for Croup C was

$1589.16 saving $70.65 compared to Group A. One-way ANOVA

was significant (p = 0.043). On post hoc analysis, the only statistical

difference was between Group B and Group C (p = 0.008). We cal-

culate that after 15 cases, R-TAPP training becomes cost-neutral.

Conclusion: The lean start-up methodology enables a cost-neutral

approach to robotic surgery training and can contribute to the sus-

tainability of academic robotic training programs.

123

S14 Hernia (2019) 23 (Suppl 1):S13–S14


Session 4A: Should We Be Gambling with Our Hernia Patients? Innovation with RiskSharing Is a Better Bet


IP-1316

Barracuda tank follow up: mesh suture

Dumanian GChicago, IL

ABSTRACTS

123



Session 4B: Scientific Abstracts—Ventral Hernia


FP-1260

Prehabilitation in underserved, minority patients

with ventral hernias: long-term results of a randomized

controlled trial

Bernardi K, Bernardi K, Olavarria O, Holihan J, Cherla D,

Berger D, Ko T, Liang MMcGovern Medical School UTHealth

Background: Previously, we demonstrated that prehabilitation, or

preoperative nutritional counseling and exercise, at a safety net hos-

pital can help patients achieve preoperative weight loss goals and

results in more patients who are hernia-free and complication-free

7-months post-randomization. We hypothesized that prehabilitation in

underserved, obese patients seeking ventral hernia repair (VHR)

results in more hernia- and complication-free patients at 2 years post-

randomization.

Methods: This was a blinded randomized controlled trial at a safety-

net academic institution. Obese patients (BMI 30–40) seeking VHR

were randomized to prehabilitation versus standard counseling.

Elective VHR was performed once preoperative requirements were

met: 7% total body weight loss or 6 months of counseling and no

weight gain. Primary outcome was percentage of hernia-free and

complication-free patients at 2 years post randomization. Complica-

tions included recurrence, re-operation, and mesh complications (i.e.

mesh infection).

Results: A total of 118 patients were randomized, 110 (93.2%)

completed a median (range) follow-up of 26.6 (19.1–35.6) months.

Baseline BMI (mean ± SD) was similar between the groups (preha-

bilitation 36.8 ± 2.6 and standard counseling 37.0 ± 2.6). At late

follow-up, there was no difference in the percentage hernia-free and

complication-free patients (75.0% vs 68.5%, p = 0.527). Almost half

of all patients, 44.2% in prehabilitation and 43.2% in standard

counseling, gained weight over their baseline and 14.5% of patients

(prehabilitation = 5, standard counseling = 10) sought VHR else-

where. Underserved minorities lost less weight on average (8.6 vs

13.8 lbs, p = 0.048) and had a lower percentage of patients were

hernia-free complication-free (65.6% vs 75.0%).

Conclusions: While prehabilitation prior to VHR is feasible and

effective in the short-term at a safety-net hospital, there was no dif-

ference in long-term results. This may be because patients often

regain the weight they lost or seek VHR elsewhere after failing

preoperative requirements. Continuing diet and exercise programs

after VHR, along with national guidelines, and changes in compen-

sation may be important components of tackling VHR in obese

patients.

FP-1189

Comparative efficacy of transversus abdominis plane

blocks and epidural catheters following posterior

component separation hernia repair

Morrell D, Pauli E, Doble J, Hendriksen B, Hollenbeak CPenn State Health Milton S. Hershey Medical Center

Introduction: Recovery protocols have become a point of emphasis

in postoperative care following ventral hernia repair (VHR). How-

ever, little is known about the contribution of a protocol’s individual

components on measurable patient outcomes. This study evaluates the

efficacy of two postoperative analgesia modalities—epidural catheter

or transversus abdominis plane block (TAP-block) following VHR

performed via transversus abdominis release (TAR).

Methods: A retrospective analysis was performed on data prospec-

tively collected between 2012 and 2018. All patients undergoing

VHR via TAR performed by a single surgeon were identified.

Parastomal hernia repairs were excluded. During the study time

frame, the only change made to the recovery protocol was the

modality of post-operative analgesia (epidural or TAP-block). The

dataset was augmented with pain scores, opioid requirements, length

of stay (LOS), and 30-day morbidity collected from the medical

records. Linear regression was used to model LOS.

Results: One hundred fourteen patients met inclusion criteria (61

epidural, 53 TAP-block). All TAP-blocks were performed with 20 mg

of liposomal bupivacaine. The majority (75%) of patients were

modified ventral hernia working group (VHWG) grade 2. There were

no statistically significant differences in postoperative pain scores or

opioid use between the groups. LOS was significantly shorter in the

TAP-block group (4.7 versus 6.1 days, p = 0.012) as was time to

regular diet (3.1 versus 4.9 days, p = 0.0003). Epidural patients

experienced higher rates of urinary tract infection (UTI; 8.2% versus

0%, p = 0.033). After controlling for VHWG grade, surgical site

infection, pneumonia, UTI, and postoperative bleeding, epidural

increased LOS by 1.5 days (p = 0.002).

Conclusions: When compared to TAP-block, epidural use following

VHR via TAR increased LOS, time to regular diet, and UTI rates

without significantly reducing pain scores or opioid requirements.

Future study of the cost-effectiveness of epidural versus TAP-block

locoregional analgesia in VHR via TAR is warranted to refine

existing recovery protocols.

ABSTRACTS

123

Hernia (2019) 23 (Suppl 1):S16–S18

FP-1123

Repair of complex incisional hernias after liver

transplant with TAR: the experience from two hernia

centers

Tastaldi L, Blatnik J, Krpata D, Fafaj A, Alkhatib H, Petro

C, Rosenblatt S, Prabhu A, Rosen MCleveland Clinic

Introduction: The combination of midline and subcostal defects,

proximity to bony prominences and associated lifelong immunosup-

pression are factors that makes the management of incisional hernias

(IH) after orthotopic liver transplant (OLT) challenging. We aim to

report the outcomes of IH repair after OLT using a posterior com-

ponent separation with transversus abdominis release (TAR).

Methods: Post-transplant patients who underwent open, elective IH

repair using TAR and with a minimum of 1-year follow-up were

identified in the Americas Hernia Society Quality Collaborative.

Repairs were performed at two Hernia Centers with permanent syn-

thetic mesh placed in sublay position. Outcomes included 30-day

surgical site infections (SSI) and surgical site occurrences requiring

procedural intervention (SSOPI), unplanned readmissions, reopera-

tions, and hernia recurrence. Recurrence was determined by clinical

examination, imaging studies or using the Ventral Hernia Recurrence

Inventory.

Results: Forty-four patients were identified (mean age 60 ± 8, 75%

males and median BMI 30.7 kg/m2); all were under immunosup-

pression at time of surgery. Median hernia width was 20 cm (IQR

15–27.5) and 98% were clean cases. Fascial closure was achieved in

41 (93%) and there were no intraoperative complications. There were

5 SSIs (4 deep, 1 superficial), 5 SSOPIs (4 wound opening and 1

debridement) and one patient had a mesh infection. Four patients

(9%) were readmitted and 3 patients (6.8%) required reoperation (2

due to 1 bleeding, 1 due to SSI). After a median follow-up of

13 months (IQR 12–17), the recurrence rate was 25%, mostly driven

by central mesh failures. Repair of such recurrences were performed

through onlay or laparoscopic approaches.

Conclusions: In a challenging cohort of patients with large IH, TAR

was shown to have acceptable medium-term results. Further studies

investigating the factors leading to central mesh failures are necessary

to reduce recurrence.

FP-1216

Laparoscopic ventral hernia repair: results

and challenges of long-term follow-up

Lew M, Lewis R, Landry M, Ramshaw B, Forman BUniversity of Tennessee, Knoxville

Background: Laparoscopic ventral hernia repair is a commonly

performed procedure. Although short-term follow-up results have

been frequently published, long-term follow-up remains challenging.

Methods: We implemented a clinical quality improvement (CQI)

program for ventral hernia patients to better measure and improve

outcomes. From 2012 to 2015, 117 consecutive laparoscopic ventral

hernia repair patients from a single hernia program were evaluated.

Long-term follow-up was attempted through a variety of methods

including phone, email and in person clinic visits.

Results: A total of 117 patients had 4 known recurrences, 3 patients

developed chronic pain after hernia repair (two had mesh removal) and

one patient died from aspiration on POD #3. Overall, 54% of patients

were female, mean age was 59, mean BMI was 53.4, and 56% had a

recurrent hernia (1–13 prior repairs). The mean hernia size was 96 cm2,

and mean mesh size was 538 cm2. The attempts to obtain follow-up data

were challenging. Despite multiple attempts and a variety of mecha-

nisms, only 82 patients (70%) have follow-up data for 18 months or

longer (mean 37.2 months, range 18–76 months). Reasons for cessation

of follow-up included deaths unrelated to the hernia repair, but some

patients refused to continue being contacted due to their worry about

unpaid hospital bills and their concern about hernia mesh litigation.

Conclusion: Even with a dedicated hernia program, recurrences and

complications do occur and obtaining long-term follow-up is difficult

after laparoscopic ventral hernia repair. Challenges with obtaining

long-term follow up likely undercount recurrences and complications

and inhibit learning. Innovative methods to increase follow-up can

lead to more accurate outcome measurements and eventually help

lead to improved patient outcomes.

FP-1124

Lateral abdominal wall hernias: a single institution

review of 116 consecutive flank and lumbar hernia

repairs

Schlosser K, Maloney S, Prasad T, Colavita P, Augenstein

V, Heniford BCarolinas Medical Center

Aims: Lateral abdominal wall hernia repair (LAWHR) is a surgical

challenge, as defects often extend to paraspinal muscles and are

bordered by bone on one or multiple sides. This study examines the

outcomes of LAWHR as compared to ventral hernia repair (VHR).

Methods: A prospective, single-center, hernia-specific database was

queried for LAWHR and VHR with preoperative CT scans (2007–2018).

Demographics, operative characteristics, and outcomes were evaluated.

Results: 116 LAWHR and 1022 VHR were identified. Mean age was

58.3 ± 12.4 years, BMI 33.1 ± 7.3, and 58.3% were females. When

compared to VHR, LAWHR had lower BMI (30.4 ± 6.0 vs

33.8 ± 7.5 kg/m2, p = 0.002), smaller defect size (median 68.6, IQR

40.3–135.0 vs. 105.1, IQR 46.6–226.2 cm2), and fewer previous

hernia repairs (median 1, IQR 1–2 vs. 2, IQR 1–3). 63% of LAWR

were incisional, 22% blunt trauma, and 15% primary. More VHR had

concomitant panniculectomy (37.4 vs. 3.5%, p\ 0.0001), Class II-IV

wounds (28.8 vs. 6.0%, p\ 0.001), and component separation (50.4

vs. 20.7%,\ 0.0001), with equivalent rates of primary fascial closure

(89.5 vs. 93.1%, p = 0.2). VHR had higher surgical site occurrence

(SSO 32.5 vs. 16.0%, p\ 0.0001), surgical site infection (SSI 24.1

vs. 12.1%, p = 0.004), and recurrence (12.3 vs. 2.6%, p\ 0.0001).

LAWHR showed a higher incidence of postoperative pain requiring

further intervention, (43.4% vs. 20.0%, p\ 0.0001), such as referral

to pain specialist (34.3% vs. 14.3%) and/or suture site injection (11.2

vs. 6.8%). Median follow up was 18.2 months (IQR 2.1–54.7).

Multivariate analysis controlled for potential confounding factors

(defect size, previous surgeries, contamination, and concomitant

procedures). No significant difference in SSI or SSO was noted

between LAWHR and VHR. LAWHR had lower reoperation (OR 0.3,

CI 0.1–0.8) and recurrence (OR 0.2, CI 0.05–0.9), and higher post-

operative pain requiring intervention (OR 3.8, CI 2.3–6.4).

Conclusion: Differences in etiology and complexity make LAWHR a

significantly different patient population than VHR. The high inci-

dence of patient pain requiring intervention after repair warrants

further investigation.

123

S17 Hernia (2019) 23 (Suppl 1):S16–S18

FP-1163

Polylactide-caprolactone composite mesh used

for ventral hernia repair: a prospective, randomized,

single-blind controlled trial

Shen Y, Chen J, Qin CBeijing Chao-Yang Hospital, Capital Medical University

Objective: Composite surgical mesh is widely used in laparoscopic repair

of ventral hernia but may carry the risk of postoperative adhesion andmore

serious complications. The present study was undertaken to demonstrate

the effectiveness and safety of a new composite polypropylene mesh

coated with poly L-lactide-co-e-caprolactone (EasyProsthesTM) .

Methods: This randomized, controlled trial was designed to compare

EasyProsthes composite mesh (EPM) with ParietexTM Composite

(PCO) in patients undergoing laparoscopic ventral hernia repair (with or

without the hybrid technique). Hernia recurrence, chronic pain, seroma

formation, intestinal fistula and obstruction, wound or abdominal

infection, and ultrasound evidence of viscera adhesion were evaluated.

Results: Forty patients were randomly assigned to each of the EPM

and PCO groups. All patients completed 24 months of follow-up. One

patient in EPM group (2.5%) and two patients in PCO group (5%)

developed mesh-viscera adhesions after surgery (p = 1.000). No

patients developed intestinal fistulas or obstructions. Seventeen

patients in EPM group (42.5%) and 21 in PCO group (52.2%)

developed post-surgical seromas in the operative area (p = 0.370).

One patient from each group developed postoperative wound infec-

tion. There were no cases of abdominal infection and no reports of

chronic pain or hernia recurrence.

Conclusions: The incidence of postoperative complications in EPM

group was similar to that seen with PCO. EPM is safe and effective

when used in ventral hernia repair.

FP-1202

Nanoscience and hernia surgery: a sexy future

or a dream that will never come truth?

East B, de Beaux A, Mickova A, Divin R, Otahal M,

Sovkova V, Vocetkova K, Amler E, Lischke RFN Motol

Introduction: With the growing number of patient complaints related

to various long term side effects of surgical meshes, the search for the

ideal mesh is still on. Reconsidering the mechanical properties of a

standard surgical mesh, and accepting a theory of ‘‘bio’’-scaffolding,

nanofibrous materials that pose the 3D structure of an extracellular

matrix may speed up the initial stages of tissue repair/healing.

Materials and methods: Polycaprolactone (PCL) is a soluble slowly

biodegradable polymer from the polyester family widely used in tissue

engineering. This polymer was tested in forspan or electrospun forms,

by itself, or embedded with growth factors and platelet rich plasma, or in

combination with large pore polypropylene mesh (composite). ‘‘Spray-

on’’ nanofibers were also tested. All spun PCL preparations were

quantified by scanning electron microscopy. Tests were performed

in vitro on 3T3 fibroblasts and in vivo (rabbits, minipigs). Standard large

pore PP mesh and plain suture were used as controls.

Results: Large variability in the diameter of nanofibers produced was

seen depending on the solution ratios, voltage and method of pro-

duction. Dynamic creep properties of healing fascia (both static and

dynamic) were significantly better in the suture compared to PP mesh

group after 6 weeks of implantation. Composite mesh showed better

incorporation than PP mesh. Plain nanofibers had the most favorable

results with the surrounding collagen showing the highest level of

maturity and alignment. However, there was marked variability in

tissue healing response depending on the diameter of the spun PCL.

Conclusion: Spun PCL as a slowly resorbable biological scaffold

‘mesh’ shows significant benefits in both in vitro and in vivo studies

in terms of healing response. The diameter of the spun PCL is one of

many variables to be determined before the era of nanomedicine will

become a clinical reality.

FP-1141

Early outcomes following use of autologous fenestrated

cutis grafts in hernia repair

Hodgdon I, Rajo M, Greiffenstein P, Cook M, Paige J, Yoo

A, Dooley DLSU Health Science Center, New Orleans

Purpose: Hernia repairs are among the most common operations

performed worldwide. Mesh is commonly used, but carries significant

risk, including seroma, infection, fistula, and recurrence. These con-

tribute to increasing healthcare costs. The use of full thickness skin

graft confers many theoretic and economic advantages over the use of

biologic or synthetic mesh. This multi-center retrospective review

examines our results of cutis autograft repair of abdominal wall and

groin hernias.

Method: Following institutional IRB approval, patients who under-

went ventral or groin hernia repair with autologous tissue graft

between March 1 and August 31, 2018 were identified. Demographic

and outcome data was harvested for review. Primary endpoints were

incidence of surgical site infections, seroma, hematoma, and hernia

recurrence. 102 consecutive patients were included. Mean follow up

time was 2.6 months.

Results: Open and laparoscopic techniques were employed (89% vs

11%) to repair 100 hernias (91 ventral, 9 inguinal). Cutis graft was

used for hernia prophylaxis in two patients. Follow up data was

available for 88 patients. We noted 13 surgical site infections, seven

requiring IV antibiotics. There were six patients who presented with

seroma, two requiring evacuation. Three patients had a postoperative

hematoma. There were no hernia recurrences or need for graft exci-

sion. There were two deaths during the study period.

Conclusion: Early outcomes following autologous cutis graft are

similar to those reported in the literature regarding traditional mesh

repair. To the best our knowledge, this is the largest modern retro-

spective review of patients who have undergone hernia repairs with

fenestrated de-epithelized full thickness skin grafts. This is also the

only report of cutis graft being placed either laparoscopically or in the

retrorectus space. Though further studies are needed, our early results

suggest that fenestrated de-epithelialized cutis grafts may be a viable,

cost effective mesh alternative in hernia repair surgery.

123

Hernia (2019) 23 (Suppl 1):S16–S18 S18


Session 5: The Great Debate: Mesh, Litigation, Petrochemicals and the Patient(Panel Session)


IP-1317

Perceptions of mesh use in hernia repair

Towfigh SBeverly Hills Hernia Center

.

IP-1318

The problem with hernia mesh: perspective

from the Plaintiff’s Bar

Lee LSouth Easton, MA

.

IP-1319

Medicolegal defense of hernia mesh related lawsuits

Myers A.

IP-1296

What’s the rate of long-term mesh related

complications in ventral hernia repair?

Bisgaard THvidovre Hospital, University of Copenhagen

Background: To reduce the risk of recurrence mesh reinforcement in

patients undergoing an umbilical- and incisional hernia repair. With-

long term follow up the benefits attributable to a mesh may be offset

in part by mesh-related complications. 1–2.

Methods: Results on long-term complications are based on data from

nationwide cohort studies.

Results: Following umbilical hernia repair the rate of chronic pain is

roughly 5% 3, recurrence 10% 3, mesh-related complications\ 1%,

and claim for financial compensation 0.5%. The hernia recurrence

rate is twice as high in a mesh-free repairs. Following incisional

hernia repair the rate of chronic pain is 15–16% 6, recurrence 15–22%

2, mesh-related complications 4–6% 2, and litigation claim rate 0.9%

4–5. The hernia recurrence rate is 2–3 higher in mesh-free repairs 2.

Conclusion: Mesh should be used as standard in incisional hernia

repair. However, patients should be informed preoperatively that the

beneficial effect of mesh to reduce hernia recurrence may be at risk

for chronic pain and surgical complications. The necessary safety of

the use mesh should be established by routinely use of long-term

marketing surveillance of mesh products.

References1. Poulose D. Ann Surg (2014)

2. Kokotovic et al. JAMA (2016)

3. Christoffersen et al. Am J Surg (2015)

4. Ahonen-Siirtala et al. Scand J Surg 2914

5. Lundsmark et al. Scand J Surg (2018)

6. Christoffersen et al. BJS (2015)

IP-1320

Is it acceptable to use petroleum-derived meshes

in hernia repair?

Benvenuto MDetroit, MI

.

IP-1281

Biologics and bioabsorbable mesh: can we avoid

the issues with synthetic mesh in ventral hernia?

Roth JUniversity of Kentucky

The use of mesh has been widely accepted as the gold-standard for

ventral and incisional hernia repair due to the demonstrated reduction

in hernia recurrence relative to suture based repairs. Synthetic meshes

are the most frequently utilized meshes with proven outcomes and

relatively low cost, thus providing excellent value in hernia care.

However, the use of synthetic mesh is associated with significant

ABSTRACTS

123

Hernia (2019) 23 (Suppl 1):S19–S20

infrequent complications that include erosion, infection, contracture,

fistula, obstruction, and chronic pain. Additionally, all synthetic

meshes are contraindicated for use in contaminated surgical fields,

although their use in this environment has been reported. The ideal

strategy for managing patients with complex ventral hernias with any

degree of contamination is often debated. Studies have demonstrated

an increased incidence of mesh infection, complications, and recur-

rence when synthetic mesh is implanted in clean-contaminated and

contaminated hernia repairs. Alternatives to synthetic mesh have

evolved due to the clinical need for a durable hernia repair without the

use of a permanent implant. Biologic meshes demonstrated early

promise for complex ventral hernia repair but have fallen out of

mainstream clinical use as a result of variability in clinical outcomes.

Favorable outcomes have been reported with biologic mesh hernia

repairs when utilized as an adjunct to primary fascial closure, most

commonly with the use of component separation techniques but

bridged repairs have universally resulted in failure. Bio-absorbable

meshes have recently emerged as a cost-effective alternative to bio-

logic meshes. Early and mid-term clinical outcomes with bio-

absorbable meshes have demonstrated safety and promising results in

complex hernia patients, although randomized comparative trials have

not been performed. Outcomes with synthetic, biologic and bioab-

sorbable mesh for complex hernia repair will be reviewed and an

algorithmic approach to complex and contaminated hernia repair will

be discussed.

IP-1321

#Meshisbad: how do we talk to patients?

Heniford BCarolinas Medical Center

123

S20 Hernia (2019) 23 (Suppl 1):S19–S20


Session 6A: The Changing Face of Hernia Surgery:Defining Who We Are (Panel Session)


IP-1322

The pathway to equity: intentional steps to foster

diversity in our profession

Bass BHouston Methodist

.

IP-1323

Better together, reflections of the first woman Americas

Hernia Society President


.

IP-1324

Working toward gender equality in hernia surgery:

the role of men

Janis JThe Ohio State University Wexner Medical Center

.

IP-1298

South American perspective on diversity among hernia

surgeons

Dorado EFundacion Valle del lili

Introduction: Laparoscopy inguinal hernia surgery is the new diva,

all surgeons are interested in learning the technique but there are

conditions in developing countries such as Central and South America

that make this procedure have some additional challenges.

Main: Evaluate knowledge before and after having inguinal hernia

training programs in Central and South American surgeons.

Methods: According to the needs and wishes of surgeons to learn

laparoscopic techniques in inguinal hernia, a diploma is created that

meets the academic requirements of university endorsement and a

program that covers the basic knowledge to safely perform this

technique. An evaluation was made on the previously about the

knowledge in both open and laparoscopic techniques in inguinal

surgery, and evaluated what facilities they have in their respective

countries and cities to perform laparoscopic hernia surgery and the

availability of meshes, fixers, balloons.

Results: The diploma opens in June 2018, at the end of the year there

were already 3 courses held with surgeons from Colombia, Ecuador,

Costa Rica. A total of 20 people did it. 100% carried out the survey,

of this, 98% had not performed anatomical techniques, and none had

done Shouldice. 20% had attended courses sponsored by laboratories

and 10% had made TAPP. 100% were unaware of the concept of

critical vision in lap inguinal surgery. 100% were unaware of the

approach and management of chronic inguinodynia or how to perform

an adequate radiological evaluation in patients with inguinal

pathology.

Conclusion: The value of graduates with solid academic content

allows the surgeon who does it beyond learning a surgical technique

to approach the patient in an integral way, avoid and know how to

handle complications and perform this type of procedures in a

responsible manner.

ABSTRACTS

123



Session 6B: Scientific Abstracts—Abdominal Wall Reconstruction


FP-1198

Current trends and practices in complex abdominal

wall reconstruction: results of a physician survey

Podolsky D, Mehta A, Krikhely A, Ghanem O, Malcher F,

Novitsky YNew York Presbyterian, Columbia University Medical Center

Background: Component Separation (CS) procedures have become

an important part of surgeons’ armamentarium. However, the exact

criteria for training, procedure/mesh choice, as well as patient

selection for CS remains undefined. Herein we aimed to identify

trends in CS utilization between various cohorts of practicing

surgeons.

Method: Members of the Americas Hernia Society were queried

using an online survey. Responders were stratified according to their

experience, practice profile ( private vs academic, general vs

hernia surgery ) and volume (low (\ 10/year) vs high) of CS

procedures. We used Chi squared tests to evaluate significant asso-

ciations between surgeon characteristics and outcomes.

Results: 266 responses with overwhelming male preponderance

(88%) were collected. The two most common self-identifiers were

‘‘general’’ (65%) and ‘‘hernia’’ (28%) surgeon. PCS was the most

commonly (68%) used type of CS; endoscopic ACS was least com-

mon (3%). Low-volume surgeons were more likely to utilize the ACS

(p\ 0.05). Only 7% that use PCS learned the technique during their

residency, as compared to 37% that use ACS. 44% felt 5–10 cases

was sufficient to become proficient in their preferred technique.

10 cm-wide defect was the most common indication; 42% had used it

for 5–8 cm defects. Self-identified ‘‘hernia’’ and high-volume sur-

geons were more likely to use synthetic mesh in the setting of

previous wound infections and/or contaminated field (p\ 0.05).

More general/low-volume surgeons use biologic mesh. Contraindi-

cations to elective CS varied widely in the cohort, and 9.5% would

repair poorly optimized patients electively. Severe morbid obesity

was the most feared comorbidity to preclude CS.

Conclusion: The use of CS varies widely between surgeons. In this

cohort, we discovered that PCS was the most commonly used tech-

nique, especially by hernia/high-volume surgeons. There are

differences in mesh utilization between high-volume and low-volume

surgeons, specifically in contaminated fields. Despite its prevalence,

CS training, indications/contraindications, and patient selection must

be.

FP-1061

Appreciation of post partum changes of the rectus

muscles in primary and Re-Do abdominoplasty

Janes L, Fracol M, Dumanian GNorthwestern Memorial Hospital

Background: Abdominoplasty is one of the top five most commonly

performed cosmetic procedures. While widening of the linea alba is a

well-accepted consequence of pregnancy, the changes to the rectus

abdominis muscles are less well known and thus unappreciated and

undertreated.

Methods: After IRB approval, the Northwestern Enterprise Data

Warehouse identified nulliparous and multiparous women, age 18–45,

who underwent abdominal CT between 2000 and present. Measure-

ments included the width and cross sectional area of each rectus

muscle, width of the linea alba, and circumference of the abdominal

cavity at the level of the L3 vertebra. In addition, two case reports

addressing these anatomical changes with muscle modification and

mesh reinforcement are presented.

Results: 60 women were identified that met our inclusion criteria: 15

nulliparous, 15 after 1 pregnancy (para 1), 15 after 2 pregnancies

(para 2), and 15 after 3 or more pregnancies (para C 3). The linea

alba was significantly widened after one pregnancy from 1.14 to

2.29 cm, but did not significantly widen further with each subsequent

pregnancy. The width of each rectus muscle was significantly

widened from 6.00 cm (± 0.60) in nulliparous to 6.61 cm (± 0.58) in

para 1, significantly widened again to 7.03 cm (± 0.46) in para 2, but

not significantly widened after that [6.97 cm (± 1.00) in para 3].

Conclusions: In addition to widening of the linea alba, pregnancy

alters the shape of the rectus abdominis muscle. Correction of muscle

width during abdominoplasty may increase abdominal tone and be a

necessary adjunct in revision procedures.

ABSTRACTS

123

Hernia (2019) 23 (Suppl 1):S22–S24

FP-1265

The incremental impact of obesity and smoking

on surgical site infections after complex abdominal wall

reconstruction

Shover A, Park H, Dubina E, de Virgilio C, Kim D,

Moazzez AHarbor-UCLA Medical Center

Introduction: Surgical site infections (SSIs) after complex abdominal

wall reconstructions (AWR) are potentially preventable and can be

associated with significant consequences. Previous studies have

identified smoking and BMI as risk factors for SSI after complex

AWR, but cutoffs were in large part selected arbitrarily. Our objective

was to analyze and better characterize the association between these

two factors and SSIs.

Method: Patients with a primary diagnosis of a ventral hernia who

underwent an open ventral hernia repair with component separation

were extracted from the ACS-NSQIP 2005–2016 database. Bivariate

and multivariate logistic regression were used to determine the risk

factors associated with SSI. Classification and Regression Tree

(CART) analysis were performed to characterize the relationship

between smoking, BMI and SSIs.

Results: There were 11,978 patients who underwent complex AWR,

with 1369 patients (11.4%) who experienced an SSI following their

AWR. On bivariate analysis, modifiable risk factors including tobacco

use and BMI were associated with a risk of SSI (p\ 0.001). On

multivariate regression analysis, tobacco use (OR 1.5; 95% CI

1.3–1.8), BMI (OR 1.0; 95% CI 1.02–1.04), inpatient status (OR 1.9;

95% CI 1.4–2.7), and White race (OR 1.2; 95% CI 1.1–1.5) were

independently associated with SSIs. CART analysis demonstrated that

the lowest SSI rate occurred in non-smoking patients with a BMI\31 (6.8%), while the highest SSI rate was seen in smokers with a

BMI[ 43 (27.5%). Additionally, BMI had an incremental impact on

the rate of SSIs as BMI increased from 31 to 43, while smoking posed

an additional increased risk in each BMI group.

Conclusion: Among patients undergoing complex AWR, the risk for

SSIs starts at a lower BMI than previously described. Preoperative

optimization of modifiable risk factors including obesity and com-

plete smoking cessation should be attempted before these cases, while

considering the incremental risk associated with BMI during opera-

tive planning.

FP-1075

The impact of inadvertent enterotomy during open

abdominal wall reconstruction (Awr)

Kao A, Huntington C, Maloney S, Prasad T, Colavita P,

Kercher K, Augenstein V, Heniford BCarolinas Medical Center

Introduction: Prior history of abdominal procedures often increases

difficulty of adhesiolysis during AWR and increases the risk of

enterotomy. The impact of enterotomies on outcomes remains poorly

described.

Methods: A prospectively collected database was queried for patients

who underwent open AWR. Patients with and without enterotomies

were compared using standard statistical methods. Contaminated

cases for reasons other than enterotomy were excluded. Quality of life

(QOL) was determined by the Carolinas Comfort Scale.

Results: 2479 patients (47 enterotomies, 2432 without) underwent

AWR. Patients’ age was similar, but enterotomy patients had

increased BMI (34.4 vs. 32.2 kg/m2, p = 0.01) and more previous

abdominal operations (100% vs. 80.2%, p\ 0.0001), including failed

VHR (76.6% vs. 48.3%, p = 0.0001) and colectomy (29.8% vs.

13.9%, p = 0.005). Inadvertent enterotomy rates were higher in

Ventral Hernia Working Group grade 3 (83% vs. 19.4%, p\ 0.0001)

or grade 4 (6.4% vs. 0.9%, p\ 0.0001) hernias and patients with

prior mesh infections (14.9% vs. 4.3%, p = 0.0004), occurring in

8.5% of all patients requiring mesh removal. After 28 months mean

follow-up, enterotomy patients had increased complications: seroma

(25.5% vs. 6.4%, p = 0.004), wound infection (23.4% vs. 6.9%,

p = 0.005), and sepsis (8.5% vs. 0.5%, p = 0.0002). Reoperation

(40.4% vs. 8.4%, p\ 0.0001), readmission (31.9% vs. 11.0%,

p = 0.0002), hernia recurrence (27.7% vs. 4.9%, p\ 0.0001), mesh

infection (10.6% vs. 1.2%, p = 0.0008), and median hospital charges

($63,657 vs. $32,522, p\ 0.0001) were also higher with enterotomy.

Among all patients who underwent VHR with synthetic mesh, inad-

vertent enterotomy increased reoperation (68.8% vs. 10.2%,

p\ 0.0001), wound complications (50.0% vs. 17.9%, p = 0.005), and

mesh infection (25.0% vs. 1.6%, p\ 0.0001). Increased rates of

reoperation (68.7% vs. 31.8%, p\ 0.04) and mesh infection (25.0%

vs. 4.5%, p = 0.03) were seen with synthetic mesh compared to

biologic mesh after enterotomy. Use of biologic mesh after entero-

tomy and synthetic mesh in clean cases resulted in similar QOL.

Conclusions: Enterotomies are a known risk in AWR. They are more

common in patients with previous VHR, increased BMI, and prior

wound complications or mesh infection. Enterotomy leads to higher

rates of complications, including a marked increase in synthetic mesh

infection.

FP-1231

Does loss of domain impact outcomes for abdominal

wall reconstruction procedures?

Landry M, Ramshaw B, Lew M, Lewis R, Forman BUTMCK

Background: High complication and recurrence rates often occur in

patients undergoing abdominal wall reconstruction (AWR). Patients

with a loss of domain (LOD) may have even worse outcomes due to

the added patient complexity. We describe a clinical quality

improvement (CQI) effort to assess the outcomes for patients with

LOD who undergo AW.

Methods: Patient and procedure factors and outcomes were recorded

as part of a CQI program for 133 consecutive patients who underwent

AWR from August 2011– August 2018. During this time, many

improvement initiatives were implemented, including use of long-

term resorbable synthetic mesh, utilizing long-acting local anesthetic

pain blocks as part of a multi-modal pain regimen, and more recently

a prehabilitation program including cognitive behavioral therapy

before surgery. Data was collected to compare outcomes for patients

with and without LOD who underwent AWR.

Results: Of the 133 total patients, 48 (36%) had LOD (determined at

the time of surgery). While patients were similar on some baseline

demographics, those with LOD had higher mean BMI (34.2 vs 31.7)

and higher mean number of prior repairs (3.90 vs 2.65), Patients with

LOD had a similar recurrence rate to patients without LOD (9.1% vs

9.4%) and similar 30-day readmission rates (9.1% vs 9.4%), however,

patients with LOD had a longer mean length of stay (10.0 vs

5.7 days), and a higher 30-day mortality (8.3% vs 0);

Conclusions: Based on these results, attempts at improving outcomes

for patients with LOD who undergo AWR are focusing on improving

length of stay and early mortality rate. This has led to implementing a

mandatory prehabilitation program and increased consideration of

visceral reduction to achieve facial closure and to decrease abdominal

pressure post-operatively.

123

S23 Hernia (2019) 23 (Suppl 1):S22–S24

FP-1222

Hybrid vs open abdominal wall reconstruction: early

outcomes

Addo A, Broda A, Estep A, Lu R, Zahiri R, Turcotte J,


Background: The hybrid approach to abdominal wall reconstruction

(AWR) for complex hernia defects combines minimally invasive

components separation and retromuscular dissection with open fascial

closure and mesh implantation. This combination may enhance

patient recovery compared to the open approach alone. The purpose

of this study is to evaluate operative outcomes of hybrid vs open

abdominal wall reconstruction.

Methods: A retrospective review was conducted to compare patients

who underwent open versus hybrid AWR between September 2015

and August of 2018 at Anne Arundel Medical Center. Patient

demographics and perioperative data were collected and analyzed

using univariate analysis.

Results: 65 patients were included in the final analysis, 10 in hybrid

and 55 in open groups. Mean age was greater in the hybrid vs. open

group (65.1 vs. 56.2 years, p\ 0.05). The hybrid and open groups

were statistically similar (p[ 0.05) in gender distribution, mean

BMI, and ASA score. Intraoperative comparison found hybrid

patients parallel to open patients (p[ 0.05) in mean operative time

(294.5 vs. 267.5 min), defect size (14.4 vs. 13.6 cm), mesh area and

drain placement. Mean total hospital cost was lower in the hybrid

group compared to the open group ($16,426 vs. $19,054, p = 0.43).

The hybrid group had a shorter length of stay (5.3 vs. 3.6 days,

p = 0.03) after surgery and followed for similar length of time (7.8 vs.

5.3 months, p[ 0.05). The hybrid group showed a lower trend of

seroma, hematoma, wound infection, ileus and readmission rates after

surgery.

Conclusion: A review of patient outcomes after hybrid AWR high-

light a trend towards shorter length of stay, lower hospital cost and

fewer complications without significant addition to operative time.

Long-term studies on a larger number of patients are definitively

needed to characterize the comprehensive benefits of this novel

approach.

123

Hernia (2019) 23 (Suppl 1):S22–S24 S24


Session 7A: AHS Safe Hernia Steps—Technical Tips for Common Problems in YourHernia Practice


IP-1286

Open repair of smaller ventral hernias: evidence based

decisions

van der Velde S, Blonk L, Bonjer JAmsterdam UMC

Repair of a smaller ventral hernia is a procedure often performed in

daily surgical practice, but used methods can vary widely. Ventral

hernias, according to the European Hernia Society (EHS), are broadly

divided into two groups, incisional hernias and primary ventral her-

nias (including umbilical and epigastric hernias). The definition of

small ventral hernias differs between these two groups. Incisional

hernias with a maximum width of 4 cm are defined as small, whereas

primary ventral hernias are defined small with a diameter of less than

2 cm. Although, the definition of small ventral hernias seems some-

what defined, the best surgical technique for repair remains unclear.

In clinical practice open hernia repair is the most frequently used

surgical technique for small ventral hernias. But recent studies sug-

gest that laparoscopic repair, in small ventral hernias, is associated

with less surgical site infections, shorter hospital stay and recurrence,

although a longer operative time was reported. We aim to demon-

strate an algorithm on how to approach a smaller ventral hernia,

taking into account variables like use of prosthetics, closure of the

defect, comorbidity, surgical technique, location of the hernia, width,

size, primary or recurrent hernia, based on available evidence.

IP-1325

Open Rives-Stoppa ventral hernia repair

Reinpold WGermany.

IP-1326

Laparoscopic Ipom

Stechemesser BGermany

.

IP-1327

Open inguinal hernia repair: tissue based approach

Morrison JCanada

.

IP-1328

Open inguinal hernia repair: mesh based approach

Chen DUCLA

.

IP-1329

Laparoscopic inguinal hernia repair: the critical view

Felix E.

IP-1330

Strategies for success in parastomal hernia repair

Bachman SInova.

IP-1331

Incorporating robotics into your hernia practice:

starting with the right procedures

Ballecer CArrowhead Hospital

ABSTRACTS

123



Session 7B: Video and Special Award Abstracts


FP-1125

Gender-specific outcomes after open hernia repair

(Ovhr)

Schlosser K, Maloney S, Prasad T, Colavita P, Heniford B,

Augenstein VCarolinas Medical Center

Aims: The impact of gender on surgical outcomes is poorly under-

stood. This study evaluates the impact of gender and abdominal

adiposity on outcomes after OVHR.

Methods: A prospective, single-center, database was queried for

OVHR with preoperative CT scans. Preoperative CTs were studied

using 3-D volumetric software. Demographics, operative character-

istics, and outcomes were evaluated by gender.

Results: 1103 patients (58.1% female) had pre-operative CTs prior to

OVHR. Females had higher BMI (34.6 ± 8.2vs. 31.7 ± 6.1 kg/

m2,p\ 0.0001), more previous surgeries (median 3, IQR 2–4 vs. 2, IQR

2–3, p\ 0.0001), and higher rates of asthma, previous MRSA infection,

and chronic pain (all p B 0.02). Males had higher rates of coronary

artery disease (22.1 vs. 12.3%, p\ 0.0001). Age and number of previous

hernia repairs were not different. Using 3-D volumetric software,

females had slightly smaller defects (135.5 ± 124.5 vs.

163.2 ± 143.7 cm2, p\ 0.0002), more abdominal subcutaneous fat

(7452.0 ± 3626.9 vs. 5788.7 ± 3284.7 cm3, p\ 0.0001), less total

abdominal volume (4423.5 ± 2197.1 vs. 6350.7 ± 3825.5 cm3,

p\ 0.0001), and no difference in hernia volume (952.6 ± 1230.8 vs.

912.7 ± 1361.2 cm3, p = 0.5). The ratio of hernia volume to abdominal

volume was higher in females (0.32 ± 0.51 vs. 0.21 ± 0.35,

p\ 0.0001). Females were more likely to develop wound complications

(39.0 vs. 27.5%, p\ 0.0001), complications of Clavien–Dindo grade

C 3 (CD C 3, 28.9 vs. 30.1%, p = 0.003), and to require readmission

(27.2 vs. 16.0%, p\ 0.0001). Multivariate analysis was performed to

control for potentially confounding factors (age, chronic pain, defect

size, number of previous surgeries, hernia to abdominal volume ratio,

subcutaneous fat volume, component separation, panniculectomy).

Subcutaneous fat volume was associated with readmission (OR 1.006, CI

1.001–1.011) and wound complications (OR 1.01, CI 1.006–1.02).

Hernia to abdominal volume ratio was associated with increased LOS

(2 day, SE 0.7, p = 0.003) and complications (CD C 3 OR 2.14, CI

1.35–3.39). Females had shorter LOS (- 1.1 days, SE 0.6, p = 0.049),

higher readmission rate (OR 1.98, CI 1.29–3.04), but no difference in

surgical site occurrence, infection, procedural intervention, or CD C 3.

Conclusion: Females undergoing OVHR are more comorbid, with

more subcutaneous fat and less total abdominal volume resulting in

higher rates of adverse outcomes and readmissions. The etiology of

these outcomes is not fully explained by identified comorbidities and

warrants further investigation.

FP-1145

Socioeconomic disparity exists among those undergoing

emergent hernia repairs in the state of New York

Docimo S, Yange J, Sun S, Zhu C, Bates A, Talamini M,

Spaniolas K, Pryor AStony Brook Medicine

Introduction: Socioeconomic factors predispose certain populations

to emergent operative procedures. This study evaluates the role of

socioeconomic factors in emergent ventral hernia repairs (EVR),

inguinal repairs (EIR), and umbilical repairs (EUR).

Methods: All patients undergoing ventral, inguinal, and umbilical

hernia repairs from 2008 to September of 2015 in the SPARCS

database were identified. Chi square test with exact P-values from

Monte Carlo simulation determined marginal associations between

repairs (elective vs. emergent) and patient characteristics (gender, age,

race, payment, and region) and co-morbidities. Multivariable logistic

regression models were utilized to examine socioeconomic disparity.

Results: 107,887 ventral, 66,947 inguinal, and 63,515 umbilical

hernias (total 238,349) were noted. Blacks (36.45%) were most likely

to undergo an EVR compared to whites (27.23%; OR 1.55, 95% CI

1.48–1.61), Asians (31.46%; OR 1.31, 95% CI 1.15–1.5), and His-

panics (30.05%; OR 1.3, 95% CI 1.23–1.37). Medicaid patients were

more likely to undergo EVR compared to Medicare (OR 1.44, 95% CI

1.35–1.54) and commercial insurance (OR 1.73, 95% CI 1.64–1.84).

Blacks (34.88%) were most likely to undergo EIR compared to whites

(18.86%; OR 2.2, 95% CI 2.06–2.36), Asians (24.00%; OR 1.74, 95%

CI 1.49–2.02), and Hispanics (27.17%; OR 1.22, 95% CI 1.12–1.34).

Medicaid patients were more likely to undergo EIR compared to

Medicare (OR 2.92, 95% CI 2.65–3.22) and commercial insurance

(OR 4.55, 95% CI 4.19–4.94). Blacks (31.02%) were most likely

undergo EUR compared to whites (24.94%, OR 1.29, 95% CI

1.22–1.36), Asians (26.62%, OR 1.21, 95% CI 1.01–1.46) and His-

panic (28.03%, OR 1.08, 95% CI 1.01–1.16). Medicaid patients were

more likely to undergo EUR compared to Medicare (OR 1.63, 95% CI

1.49–1.78) and commercial insurance (OR 2.31, 95% CI 2.15–2.47).

Conclusion: Race and economic status are contributing factors in

who undergoes an emergent hernia repair in New York State.

IP-1332

Registry-based, randomized controlled trial comparing

intra-operative Foley catheter versus no catheter

for minimally invasive inguinal hernia repair

Fafaj ACleveland Clinic.

ABSTRACTS

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Hernia (2019) 23 (Suppl 1):S26–S27

IP-1333

Perioperative analgesia with transversus abdominis

plane (Tap) block versus epidural analgesia: analysis

from the americas hernia society quality collaborative

Saad IGreenville Health System

.

V-1186

Re-Do Tar

Tastaldi L, Fafaj A, Alkhatib H, Svestka M, Petro C,

Krpata D, Rosenblatt S, Prabhu A, Rosen MCleveland Clinic

The posterior component separation with transversus abdominis

release (TAR) is an efficient technique in the surgical armamentarium

for the repair of large and complex hernia defects. Driven by the

ability to provide tension-free fascial closure with wide mesh overlap

in sublay position while obviating subcutaneous flaps raising, TAR

gained significant popularity and was adopted by a large number of

general surgeons. Nevertheless, unforeseen complications are inher-

ent to the adoption of an innovative technique or device and the

effects of this widespread adoption remain unknown. One of such

complications has been reported by some surgeons: lateral recur-

rences due to linea semilunaris disruption. In this scenario, a

misunderstanding of the abdominal wall anatomy and surgical planes

can lead to disruption of the linea semilunaris and results in complete

separation of the lateral abdominal wall musculature from their

insertion into the rectus abdominis. In this scenario, a combination of

lateral and midline recurrences along with muscle denervation results

in severely complicated defects. To illustrate such complication, the

case of a 63-year old female w/prior history of transverse colectomy

c/b anastomotic leak and reoperation. The patient developed an

incisional hernia that was repaired at an OSH through an open

approach; per the operative report, TAR was performed and a coated

permanent synthetic mesh was placed. A large recurrence was noted

briefly after the operation, and a CT Scan demonstrated disruption of

linea semilunaris on the right side along with posterior rectus sheath

breakdown.

We aim to present a video and discuss in a thoughtful and detailed

manner, the operative management of such complications by means

of a Re-do TAR. The operative maneuvers are shown step-by-step

and allow the audience to understand why such complications occur

and how they can be repaired in the hands of experienced surgeons.

V-1119

Panniculectomy, preoperative botulinum-toxin

A and preperitoneal ventral hernia repair in a morbidly

obese patient with loss of domain

Maloney S, Gbozah K, Heniford B, Augenstein VCarolinas Medical Center

Introduction: Preperitoneal open ventral hernia repair (PPVHR) is an

effective technique in repairing ventral hernias. By placing a mesh

between the peritoneum and the posterior rectus sheath, the mesh is

isolated from the viscera. Mesh in the preperitoneal plane is less

likely to erode into intestine, cause adhesions and requires less

transfascial sutures which in turn may decrease postoperative pain.

Case report: A 48-year-old woman, BMI 48.0 kg/m2, with a history

of hypertension and sleep apnea, presented to clinic. Her surgical

history includes an abdominal hysterectomy complicated by a post-

operative MRSA infection followed by development of a very large

suprapubic hernia with loss of domain. In preparation for surgery, the

patient lost 32 lb (BMI 42.8 kg/m2) and underwent pre-operative

botulinum-toxin A injections. Using volumetric measurements, the

32-pound weight loss resulted in a 3275 cm3 decrease in adipose

volume.

The procedure begins with a panniculectomy and dissection around

the hernia sac. Meticulous lysis of adhesions and circumferential

preperitoneal dissection were performed next. The peritoneum was

approximated over the viscera. With the defect measuring

27 9 27 cm, fascia could not be brought together. A bilateral external

oblique component separation was subsequently performed. A

30x30 cm biologic mesh was positioned diagonally for 42 9 42 cm

sublay. The mesh was secured with 8 transfascial sutures, and the

fascia was then approximated without tension. Drains were placed in

the subfascial and subcutaneous space. The panniculectomy incision

was closed, and an incisional negative pressure vac dressing was

applied.

Conclusions: PPVHR is an excellent technique for extraperitoneal

mesh placement in ventral hernia repair. Myofascial release may be

combined if needed for fascial reapproximation but PPVHR allows

for extraperitoneal mesh placement even in cases where myofascial

release is not necessary.

V-1132

Single incision laparoscopic TEP hernia repair

under local anesthesia

Wada N, Furukawa T, Kitagawa YKeio University School of Medicine

Introduction: An umbilical port is widely used in many types of

laparoscopic surgeries. For totally extraperitoneal (TEP) hernia repair,

preperitoneal dissection around umbilicus is not always necessary.

We developed a novel minimally invasive technique of single-port in

the lower abdomen laparoscopic TEP inguinal hernioplasty under

local anesthesia which is suitable for overnight hospital admission.

Materials and methods: From January 2012 to December 2015, a

consecutive group of 134 patients with bilateral inguinal hernia was

included. Obese patients, patients with giant hernia or irreducible

hernia were excluded. We used 0.5% lidocaine with epinephrine as

local anesthesia. An incision of 30 mm in the lower abdomen was

made and a wound protector with sealing silicon cap was placed. We

used three 5-mm trocars and a 5-mm flexible laparoscope. A flat self-

fixating mesh with resorbable microgrip was installed and spread over

the myopectineal orifice. No tacking devices were used.

Results: The mean ± SD age was 67 ± 10 and male sex was 84%.

The mean operating time was 176 ± 65 min. Surgical complications

were not observed except for 5 cases of minor seromas (3.7%).

Pneumoperitoneum due to peritoneal injury was occurred in 16 cases

(11.9%) and managed by suturing the defect. During median follow-

up of 32 months, we observed 1 hernia recurrence. Conclusion: The

mid-term outcomes were similar to those of conventional TEP or

open hernia repair. Surgical invasiveness of this technique was min-

imal because the area of dissection in the preperitoneal space is

smaller than that of umbilical TEP. Postoperative recovery was rapid

and patients can walk soon after surgery. This novel procedure may

be feasible in ambulatory setting.

123

S27 Hernia (2019) 23 (Suppl 1):S26–S27


Session 8A: Hot Topics in Complex Abdominal Wall Reconstruction


IP-1334

Chemical component separation: practical use

and review of the data

Heniford BCarolinas Medical Center

.

IP-1335

Why retromuscular? Onlay can do the job

Webb DMemphis, TN

.

IP-1336

Performing posterior component separation (TAR)

correctly

Novitsky YColumbia

.

IP-1337

Myofascial release after previous abdominal wall

reconstruction

Warren JGreenville Health System

.

IP-1338

Five plastic surgery tips all hernia surgeons should

know

Janis JThe Ohio State University Wexner Medical Center

ABSTRACTS

123



Session 8B: Scientific Abstracts—Ventral Hernia II


FP-1267

Prevention of incisional hernia with cutis autograft

augmentation

Yoo A, Short C, Hodgdon I, Greiffenstein P, Lau FLSU Plastic Surgery

Background: The U.S. healthcare system repairs 400,000 incisional

hernias (IH) per year. Currently mesh is the mainstay of IH repair,

however, this option is still unsatisfactory due to the inherent risks of

pain, infection and mesh extrusion. Biologic grafts have lower rates of

removal (4.9%), but the cost is significant with a 150 cm2 prosthesis

priced at $2845–$5311. Additionally, in contaminated cases, recur-

rence is 23% when repaired with mesh. Studies suggest the use of

cutis autografts as a cost-effective option that may have less associ-

ated pain, decrease recurrence and graft removal rates. To test the

effectiveness of cutis autografts we performed a double-blinded,

prospective randomized control trial using a validated rat model.

Study design: 400 g, male Sprague–Dawley rats were randomized

into 2 groups: no treatment control group (N = 17) and cutis autograft

experimental group (N = 10). Using a validated rat hernia model,

midline incisions were made and no treatment vs a dermal excision

and cutis autograft underlay intervention was applied. The abdomen

was then closed by a second blinded surgeon.

The primary endpoint was IH formation measured on post-operative

day (POD) 28 by surgeons blinded to group assignment. Secondary

endpoints included: fascia tensile strength, serum inflammatory

markers, tissue inflammatory marker expression and collagen I/III

ratio.

Results: The cutis autograft significantly reduced IH formation (10%

[1/10] vs. 82.4% [14/17] control; p\ 0.00). Secondary endpoints,

including tensile strength showed no difference (1.155 N/mm2 cutis

vs 1.219 N/mm2 control; p = 0.37). Serum CRP & IL-6, as well as

tissue IL-6, MMP11 and 13 showed no difference. Collagen I/III ratio

trended higher in cutis autograft group but again was not significant.

Conclusion: Cutis autograft underlay augmentation of facial closure

reduced IH formation rates in a double-blinded animal RCT. These

results establish the preclinical basis for studies in human subjects.

FP-1224

Computed tomography imaging in ventral hernia

repair: can we predict the need for myofascial release?

Love W, Patel P, Ewing A, Carbonell A, Cobb W, Warren

JGreenville Memorial Hospital

Introduction: The need for additional myofascial release (MR) with

transversus abdominis (TAR) or external oblique release (EOR)

during open retromuscular ventral hernia repair (RMVHR) is often

unpredictable. We developed a novel method of predicting the need

for additional MR based on preoperative computed tomography.

Methods: All patients with midline RMVHR between August 2007

and February 2018 were reviewed. Those with preoperative CT

imaging within 1 year of repair were included. Combined rectus

abdominis width to hernia width (RW:HW) ratio was determined. A

previously described component separation index (CSI), which

measures the deflection angle across the hernia defect was also tested.

Student’s t test determined differences in CSI and RW:HW. Receiver

operator curves were used to determine the highest area under the

curve (AUC) and accuracy of RW:HW or CSI to predict additional

MR.

Results: 342 patients met inclusion criteria. RMVHR alone was

performed in 208 patients, and 134 required additional MR. Mean

RW:HW was 2.4 in patients with RMVHR alone, and 1.2 in those

requiring MR (p\ 0.001). Mean CSI was 0.1 in those with RMVHR

alone and 0.18 in those requiring MR (p\ 0.001). AUC analysis

indicates a RW:HW of\ 1.3 predicted the need for additional MR

with 77.5% accuracy. CSI[ 0.15 predicted the need for additional

MR with 76.3% accuracy. Additionally, RH:HW of\ 0.74 or

CSI[ 0.19 predict the inability to achieve fascial closure even with

MR (n = 14).

Conclusion: Objective measurement of preoperative imaging using

RW:HW or CSI accurately predicts both the need for additional MR

during RMVHR. This tool may prove a useful in preoperative plan-

ning, informed consent, or the need for specialist referral.

FP-1127

The impact of weight change on intra-abdominal

and hernia volumes

Schlosser K, Maloney S, Gbozah K, Prasad T, Colavita P,

Augenstein V, Heniford BCarolinas Medical Center

Background: Weight loss is often encouraged or required before

elective operations, especially in ventral hernia repair (VHR). This

ABSTRACTS

123

Hernia (2019) 23 (Suppl 1):S29–S30

study evaluates the impact of weight change on intra-abdominal

(IAV) and hernia volume (HV).

Methods: A prospective institutional hernia database was reviewed

for open VHR patients with two preoperative CT scans and recorded

weights. Scans were reviewed using three-dimensional volumetric

software. Demographics, operative characteristics, and outcomes

were evaluated. The impact of weight change on IAV and HV was

assessed using Spearman Correlation Coefficients and linear regres-

sion models.

Results: At the time of hernia surgery, mean BMI of 167 patients was

33.9 ± 7.2 kg/m2, IAV was 3770.9 ± 1875.0 cm3, HV was

1012.5 ± 1309.9 cm3, abdominal subcutaneous fat volume (SQV)

was 6729.6 ± 3701.3 cm3, and total abdominal contents (TAC)

(IAV ? HV = TAC) was 4760.8 ± 2351.5 cm3. Mean time between

scans was 13.5 ± 9.6 months, with weight loss of 1.5 ± 15.2 kg, and

HV increase of 415.0 ± 824.3 cm3. Weight was associated with

change in IAV, SQC, and TAC (Spearman Correlation Coefficient

0.42, 0.42, and 0.48 respectively; (p\ 0.0001 all values), but not with

HV or defect size. A 5 kg weight change (gain or loss) was associated

with change of 100.5 ± 26.3 cm3 in IAV, 100.0 ± 28.9 cm3 TAC,

and 151.5 ± 44.2 cm3 SQV (p\ 0.0008 all values, linear regression

model). When examined by sex, 5 kg weight change was associated

with more change in SQV and IAV in males than females (SQV

201.5 ± 57.4 vs. 103.7 ± 62.9 cm3; IAV 109.7 ± 56.1 vs.

85.1 ± 25.6 cm3). However when stratified by sex, statistical sig-

nificance remained for only IAV in females (p = 0.001), and SQV in

males (p = 0.0008).

Discussion: Weight change is linearly correlated with intra-abdomi-

nal and subcutaneous fat gain or loss, but this correlation varies by

gender. Specifically, males show larger response to weight gain or

loss in the abdomen, while females show smaller and somewhat more

variable changes in visceral and subcutaneous fat.

FP-1168

Characterization of information on surgical mesh

for hernia repair on the internet

Miller M, Blatnik J, Arefanian SWashington University School of Medicine in Saint Louis

Introduction: Hernia repair remains one of the most common sur-

gical procedures performed in the U.S. Surgical mesh used in these

procedures offer many benefits, but there is inherent risk, which has

resulted in lawsuits and increased legal advertisement in the media.

With improving internet access, patients can read potentially biased

and incomplete information concerning mesh, and this can influence a

patient’s healthcare decisions. The goal of this study is to characterize

the presentation and content of information regarding surgical mesh

for hernia repair on websites found through internet search engines

(SE).

Methods: Websites for assessment were found using four keys word

searches targeting surgical mesh on the three most used SEs. The

websites were recorded, and sites on the first two pages of each search

were screened using an internet screening tool (IST). The IST con-

sisted of a battery of dichotomous questions to develop metrics for

website quality, content comprehensiveness, and content depth.

Results: Websites that presented papers scored significantly higher in

all three metrics (i.e. website quality, content, depth). The first four

results of every search were advertisements. Ads account for 36% of

all websites (70% were legal). Legal advertisements that presented

with higher frequency scored the lowest, and significantly lower than

Informational websites. Legal Ads and News sites were the most

skewed when comparing risks and benefits. Furthermore, these sites

referenced data specific to risk only 8% in comparison to 31% from

informational sites. Despite zeroing out search history and cookies,

46% of recommended search terms by the SEs had a negative risk/

legal bias.

Conclusions: These results emphasize the challenges of finding

comprehensive, appropriate information regarding surgical mesh.

Using a SE, the user is likely to be exposed to extraneous information

that is counter to search goals. One recommendation is to use websites

recommended by medical professionals.

FP-1170

Can we see into the future?—development of a risk

calculator app using institutional datasets for predicting

incisional hernia

Kozak G, Basta M, Broach R, Fischer J, Broach R, Fischer

JUniversity of Pennsylvania

Introduction: Incisional hernia (IH) occurs after 10–15% of all

abdominal surgeries and remains among the most challenging,

seemingly unavoidable complications. IH shares features with chronic

diseases including treatment failures, long-term morbidity, and high

healthcare costs. There is a need for a portable, bedside tool to

identify at risk patients. We aim to generate a high fidelity, user

friendly IH prediction App that considers preoperative identifiable

risk.

Method: A retrospective observational cohort study was conducted

from 2005 to 2016 at the University of Pennsylvania. All adult

patients with a clinical condition warranting abdominal surgery were

included. Independent factors associated with IH were identified and

demonstrated the utility of the electronic medical record (EMR) in

creating a preoperative risk stratification model. The model was

translated into unique hernia risk calculator App (iTunes/Android

‘‘Hernia Calculator’’) and website (pennherniariskcalc.com).

Results: Among 29,739 patients included, the incidence of operative

IH was 3.9% (N = 1127) at an average of 57.9 months follow up.

Fifteen risk factors were determined significant in univariate analysis.

Multivariate logistical regression analysis identified 5 risk factors

including emergent surgery (OR = 4.1, p\ 0.001), history of prior

abdominal surgery (OR = 2.6, p\ 0.001), smoking (OR = 1.7,

p\ 0.001), open surgery (OR = 1.6, p\ 0.001), and obesity (OR =

1.5, p\ 0.001). Variables were weighted according to ß-coefficients

generating 8 unique models determined by the index abdominal

operation. These models demonstrated excellent risk discrimination

(C-statistic = 0.76–0.89).

Conclusions: This work highlights a fully designed and integrated

risk calculator App generated from a multi-year, longitudinal multi-

hospital dataset. Surgeons may utilize it to communicate with patients

at the bedside, offer risk reductive strategies, and design stratified

cohorts for clinical trials. The App provides real-time risk estimation,

the ability print and embed risk scores in EHR, and to demonstrate the

effects of risk reductions.

123

S30 Hernia (2019) 23 (Suppl 1):S29–S30


Session 9: Special Problems in Abdominal Core Health


IP-1280

The diastasis recti problem: are there solutions

that work?

Morales-Conde SUniversity Hospital Virgen del Rocio

Rectus problems is an entity not well defined that normally surgeons

face. Most patients visit surgeons because they do not know exactly

what they have, because they are referred by their general practi-

tioners who think patients have a hernia or for cosmetic reasons, but

patient are not aware that there are some health problems that could

be associated to the diastasis, such as pelvic organ prolapse or back

pain.

Patients affected by this entity could be grouped in two: obese

patients, with or without a hernia associated, and young female post-

partum. Both groups of patients should be explored properly in order

to identify the presence of a concomitant hernia and vice versa, those

with a primary hernia of the linea alba should be investigated since a

high rate of recurrence are related to previous presence of a rectus

diastasis.

An obese patient with rectus diastasis with no hernia associated

should not undergo a surgical repair. On the other hand, those pre-

senting a hernia together with the diastasis of the middle line should

be operated of both entities at the same time, considering the mini-

mally invasive approach a good alternative. The surgical technique

should not be just focus on closing the defect of the hernia, being

necessary to reconstruct the linea alba, that could be done using

different accesses: transabdominally, placing a mesh intraabdomi-

nally or dissecting the retromuscular space and placing a mesh in this

position, or totally extraperitoneal.

Young females post-partum could be grouped in two, those with

an excessive of skin and those who do not have this problem. If the

first scenario is faced and open dermolipectomy together with a

reconstruction of the linea alba should be performed, being preferred

by our group to place a retromuscular mesh better than performing a

plication. In case there is no excessive of skin different.

IP-1339

Femoral hernia repair: practical tips

Goldblatt MMedical College of Wisconsin

.

IP-1278

Decision making in core muscle injury/sports hernia

Campanelli G, Bruni P, Morlacchi A, Lombardo F, Cavalli

MIstituto Clinico Sant’Ambrogio, Milano Hernia Center, University

of Insubria

The pubic inguinal pain syndrome (PIPS) is a clinical condition where

there is often no real hernia and it frequently occurs in professional

athletes.

The pain experienced is recognized at the common point of origin

of the rectus abdominis muscle and the adductor longus tendon on the

pubic bone and the insertion of the inguinal ligament on the pubic

bone.

Our etiopathogenetic theory is based on three factors:

– the compression of the three nerves of the inguinal region,

– the imbalance in strength of adductor and abdominal wall muscles

caused by the hypertrophy and stiffness of the insertion of rectus

muscle and adductor longus muscle,

– the partial weakness of the posterior wall.

At the beginning, our surgical procedure, after a reasonable time

of FKT, included the release of all three nerves of the region, the

correction of the imbalance in strength with the partial calibrated

tenotomy of the rectus and adductor longus muscles and the repair of

the partial weakness of the posterior wall with a lightweight or bio-

logical mesh.

In the last years, acquiring confidence in the tenotomy of the

rectus muscle and doing it always deeper, we discovered a new

anatomic finding: posteriorly to the abdominal rectus muscle, cra-

nially to its insertion in the pubic bone, where the preperitoneal fat is

usually present in normal patient with real inguinal hernia, a thick-

ened ‘‘pseudo aponeurosis’’ is found.

Its incision induces a clear release and excellent results with

complete relief of symptoms after resume of physical activity.

This new etiopathogenetic hypothesis is object of study by radi-

ologist and anatomopathologist.

Once again to note the importance to distinguish patients complain

PIPS from patients with a real inguinal hernia. Patients underwent to

ABSTRACTS

123

Hernia (2019) 23 (Suppl 1):S31–S32

unproper surgical treatment of inguinal hernia could lead to very

difficult case of chronic post-operative pain.

IP-1340

Reimbursement for hernia prophylaxis: myth

and reality

Fischer JUniversity of Pennsylvania

.

IP-1285

My patient has a mesh infection. Now what?

Hernandez-Granados PFundacion Alcorcon University Hospital

Mesh infection is one of the worst nightmares that a surgeon and a

patient can suffer. It can appear even years after the surgery. The

incidence is around 6–10%. Staphylococcus aureus is isolated in

culture sin 70% of cases. There are many risk factors for developing

mesh infection; related to the patient (tobacco, obesity) and to the

surgery (open surgery, emergent surgery, gastrointestinal surgery,

microporous meshes). Some years ago, treatment of mesh infection

leaded to mesh explantation in all cases. It can be a difficult surgery

with high risk of visceral injury, leaving abdominal wall defects

greater than the previous one and without possibility to close. Actu-

ally, conservative treatment is the preferred approach. The

conservative management starts with debridement, cleansing, sys-

temic antibiotics and negative pressure therapy. With this approach,

about 80% of macroporous meshes could be salvaged. Some authors

proposed use negative pressure therapy with instillation of saline and

they report better results with less days of treatment and high rate of

success. Laminar or composite meshes do not have this rate of salvage

and some authors have tried to perform percutaneous drainage fol-

lowed by antibiotic irrigation in selected cases. Other approach can be

partial removal of mesh when there are chronic sinuses, removing

only the piece of infected mesh identified after methylene blue

injection.

If mesh infection cannot be controlled with conservative man-

agement, explanation is recommended. Controversy exists about

single or two-staged surgery. Biologic meshes became the mesh of

choice in one-staged approach, but later on, high rate of mesh

infection, and recurrences has been reported. Now, synthetic macro-

porous meshes are recommended in contaminated cases with good

results. Biosynthetic meshes (absorbable in the long-term) would be

used in some cases but there aren�t enough information yet.

IP-1341

Ventral hernia management in the morbidly obese

patient

Higgins RMedical College of Wisconsin

.

IP-1342

Fight or flight? Ventral hernia in the emergent setting

Docimo SStony Brook, NY

.

IP-1343

Laparoscopic hiatal hernia repair: keys to success

Perry KThe Ohio State University Wexner Medical Center

.

IP-1344

Complex hiatal hernia: when to involve your thoracic

surgeon up front

Bolduc AAgusta, GA

.

IP-1345

Complex hiatal hernia: when to involve your thoracic

surgeon up front

Petersen RUniversity of Washington Medical Center

123

S32 Hernia (2019) 23 (Suppl 1):S31–S32


Session 10A: WWYD (What Would You Do?) from International Hernia Collaborationto Americas Hernia Society


IP-1279

Complication after an open transversus abdominus

release

Pakula AMarian Regional Medical Center

Introduction: Gastrointestinal leak or fistula after Transversus

Abdominus Release (TAR) is exceedingly rare and therefore no

standardized management currently exists. Given the complexity of

the problem, decisions with how to proceed can be decided through a

collaborative approach.

Methods/Results: We report a 38 year-old male with history of

necrotizing pancreatitis which required multiple operations resulting

in an open abdomen and large abdominal wall hernia. A TAR was

performed 2 years after his last operation. A medium weight

macroporous polypropolene mesh was placed in the retromuscular

space for the repair, and a closed gastric tube site was stapled off

during the repair. He recovered well during the early post-operative

period until a change in the drain output was noted, and cat scan

imaging documented that the gastric staple line was leaking into the

retromuscular space. The management of this complication involved

nasogastric tube decompression of the stomach, with the initiation of

antibiotics. The drain output decreased significantly and the staple

line dehiscence was definitively closed via an endoscopic suture

closure. Local irrigation was performed through a small opening of

the midline wound. Upper gastrointestinal contrast study was per-

formed which confirmed closure of the gastric leak. The patient’s diet

was advanced and he recovered well. 8 months follow up demon-

strates no evidence of hernia recurrence or wound issues.

Discussion/Conclusion: Gastric leak with mesh contamination fol-

lowing complex hernia repair with TAR is a rare complication. This

case demonstrates the successful management with endoscopic

methods while salvaging the hernia repair and avoiding mesh

explantation. Collaboration through the IHC helped to facilitate this.

IP-1284

Unexpected challenges in minimally invasive

management of a large ventral incisional hernia

Santos D, Limmer A, Ledet C, Gibson H, Ballecer CUniversity of Texas MD Anderson Cancer Center

Background: Minimally invasive management of large ventral inci-

sional hernias can be challenging due to the need for component

separations and patient disease. Many patients have previous surgical

interventions that increase the technical difficulty of operation. The

introduction of new technology, such as robotic surgery, can also

introduce complexity in management. We present a case of robotic

transversus abdominus release (rTAR) in a patient with Lynch syn-

drome, a Boari flap for a history of ureteral cancer, and an occult

femoral hernia.

Materials and methods: Preoperative optimization resulted in 40 lb

weight loss. A mentorship with an International Hernia Collaboration

Mentor was created. The mentee completed two tissue labs, 6 months

additional skill building with other robotic surgeries after initial

instruction in rTAR, and multiple didactic sessions in preparation for

the case. Mentee arranged collaborative practice runs with anesthesia,

nursing, and surgical technologists prior to introduction to the insti-

tution. rTAR was performed via the technique described by AM

Carbonell et al. Practice based efficiencies were evaluated.

Results: rTAR provided successful closure of the ventral incisional

hernia. Intraoperative challenges included scarring from previous

Boari flap and occult femoral hernia. Despite intraoperative practice

runs, inefficiencies persist. Patient had uneventful discharge, required

no narcotics, and had high patient satisfaction. No recurrent ventral

incisional hernia at 1 year on computed tomography, but developed

new contralateral ureteral cancer.

Discussion and conclusion: Early experience with rTAR is promis-

ing from a patient perspective. rTAR requires extensive preparation

from a mentor–mentee relationship, continuing technical improve-

ment, and practice based changes that require constant revision.

Patient disease can challenge performance of rTAR despite adequate

preparation. Feasibility and generalizability of rTAR is undergoing

evaluation.

ABSTRACTS

Hernia (2019) 23 (Suppl 1):S33–S35

123

IP-1293

Totally robotic parastomal repair with end ileostomy

reversal

Bryczkowski S, Pereira S, Rosenstock A, Zumba O,

Mazpule GHackensack Meridian Health JFK Medical Center/Surgical Practices

Associates, PA

Introduction: Creation of an ileostomy is a relatively common

operation in emergency general surgery and colorectal surgery. One

of the common complications of an ileostomy is a parastomal hernia.

This case report highlights the management of parastomal hernia

repair at the time of ileostomy reversal.

Methods: A retrospective review of the clinical records of the first

reported totally robotic parastomal hernia repair with ileostomy

reversal with video documentation. An extensive literature search was

done. The daVinci Xi� robot was used. Apple iMovie for MacOS was

used for video editing.

Results: Patient was a 72-year-old female with end ileostomy and

parastomal hernia. She initially presented with superior mesenteric

artery thrombosis secondary to large abdominal aortic aneurysm

resulting in dead bowel. After undergoing damage control laparotomy

and ileocecectomy, the patient underwent an abdominal closure and

end ileostomy. She presented for follow-up 12 months later for

reversal of the ileostomy and was found to have a large parastomal

hernia. She underwent an elective robotic end ileostomy reversal and

parastomal hernia repair without complication. The daVinci Xi robot

was used. Three 8 mm ports were placed. She underwent robotic

enterolysis, stapled division of the end ileostomy, mobilization of the

colon, and intracorporeal anastomosis using the robotic stapler. The

parastomal hernia sac was separated from the fascia. The fascia was

closed with running barbed suture. The robot was undocked and the

small portion of terminal ileum was excised. The anterior fascia was

closed in an open fashion. The skin was closed over a �’’ penrose.

She remains recurrence free at 6 month follow-up.

Conclusion: Ileostomy creation and reversal is a common operation

associated with a high incidence of complications. This case report is

the first of its kind to.

IP-1295

Robotic TAPP inguinal hernia repair complicated

by postoperative small bowel obstruction

Pereira S, Rosenstock A, Mazpule G, Zumba O,

Bryczkowski SHackensack University Medical Center

Introduction: Robot assisted laparoscopy is an increasingly common

method of inguinal herniorrhaphy. Early postoperative small bowel

obstruction (SBO) is a known potential complication of traditional

laparoscopic TAPP inguinal herniorrhaphy. Here we report a case of

early postoperative SBO following robotic TAPP inguinal hernior-

rhaphy and discussion of its management.

Methods: A retrospective review of the clinical records of a case of

early postoperative SBO following robotic TAPP inguinal

herniorrhaphy.

Results: A 58 year-old male underwent an uncomplicated robotic

bilateral inguinal hernia repair and was discharged home the same

day. He presented to the emergency department with nausea, vomit-

ing, and obstipation after previous return of bowel function on

postoperative day #2. CT imaging revealed a small bowel obstruction

with a transition point in the right lower quadrant, suspected to be at

the site of peritoneal flap closure. He was taken to the operating room

for diagnostic laparoscopy and was found to have a defect it the

peritoneal flap through which a loop of small bowel had herniated,

causing the bowel obstruction. The herniated bowel was reduced

laparoscopically, and the peritoneal defect was repaired with an

omental flap. He ultimately recovered and was discharged home in

good condition. The patient followed up and remained free of

recurrence at 12-months.

Conclusion: Early postoperative SBO following minimally invasive

inguinal herniorrhaphies are usually a result of technical failure and

caused by herniation of small bowel through a peritoneal flap defect.

It has been speculated that peritoneal flap closure during a robotic

TAPP repair may reduce the incidence of postoperative SBO. This

case highlights the potential for peritoneal flap defects to cause

postoperative SBO following robotic TAPP repairs despite meticu-

lous closure of the peritoneal flap. A high index of suspicion and early

intervention are critical for treatment.

IP-1288

Chronic small bowel obstruction after IPOM

Panait LAtlantiCare Physician Group

Introduction: Small bowel obstruction following incisional hernia

repair is not an uncommon entity. In the absence of hernia recurrence,

other potential repair-related causes should be sought.

Methods: A 45 year-old male with history of laparoscopic umbilical

hernia repair (IPOM) 6 years ago had multiple subsequent hospital

admissions for recurrent episodes of small bowel obstruction.

Extensive imaging testing was performed, but the exact cause of

obstruction was not diagnosed. His episodes resolved with conser-

vative management. Later review of the imaging studies revealed a

decompressed loop of small bowel consistently in the same position,

supraumbilically and to the right of the midline. The patient agreed to

undergo diagnostic laparoscopy in hopes of definitive diagnosis and

treatment.

Results: The diagnostic laparoscopy revealed multiple small bowel

adhesions to the mesh, with a loop being intimately adhered in

between the mesh and the abdominal wall. Robotic lysis of adhesions

was undertaken with partial removal of the mesh in order to free the

affected intestinal loop.

Conclusions: Mesh-related complications following incisional hernia

repair may present insidiously and be missed by clinical or radio-

logical examinations. Surgical intervention is sometimes necessary

for accurate diagnosis and definitive treatment.

P-1346

Hernia and diastasis: how I do it?

Leyba M.

IP-1347

Complication during open AWR: divided linea

semilunaris

DeVitis JSpectrum Health

.

123

S34 Hernia (2019) 23 (Suppl 1):S33–S35

IP-1294

Mystery finding prior to hernia surgery: a bezoar

Rosenstock A, Bryczkowski S, Mazpule G, Zumba O,

Abdelfatah E, Pereira SHackensack University Medical Center

Introduction: An incisional ventral hernia is one of the most com-

mon complications following an emergent laparotomy. Diagnostic

imaging is a routine part preoperative planning prior to ventral hernia

repair. Here we report an interesting case of a bezoar with associated

small bowel obstruction (SBO) in a 55 year-old male who presented

for elective repair of an incisional ventral hernia following emergent

sigmoidectomy and discuss the management.

Methods: A retrospective review of the clinical records of the first

reported bezoar and SBO with associated incisional ventral hernia. An

extensive literature search was done.

Results: A 55 year-old male presented with anorexia and weight loss

associated with an incisional ventral hernia 8-months following

emergent open sigmoidectomy for perforated diverticulitis done at an

outside hospital. CT imaging revealed a bezoar with an associated

SBO and ventral hernia. He was taken to the operating room and

found to have a retained operating room blue towel that eroded into

the small bowel causing a partial SBO. The towel and small bowel

were resected en-bloc with a primary small bowel anastomosis. The

ventral hernia was repaired primarily. He ultimately recovered

without hernia recurrence at so far a year and a half after surgery.

Conclusion: This case highlights a commonly talked about, but rarely

reported surgical complication of a retained foreign body. There are

even rare case reports of lap pads that have eroded into bowel. Most

importantly, though this case should be a warning to every surgeon

never to use non-radiopaque or non-countable towels in the abdom-

inal cavity. During an open transversus abdominus release hernia

repair, it taught to use a countable towel prior to starting the release to

protect the bowel. Most hospitals do not routinely stock this item, and

this case should demonstrate the potential complications of using

‘‘regular’’ blue towels.

123

Hernia (2019) 23 (Suppl 1):S33–S35 S35


Session 10B: Hernia Care in Challenging Scenarios (Panel Session)


IP-1348

Many Hernias, few resources…and no robots!

Filipi COmaha, NE

.

IP-1297

How we approach hernia repair in a tent in the Amazon

Lorenzetti C, Brandalise ACenter Medical of Campinas Foundation

Health Expeditions is a Brazilian non-profit organization founded in

2003 by a group of volunteer doctors with the goal of bringing spe-

cialized medical attention, principally surgical treatment, to the

indigenous populations who live in the isolated region of the Brazilian

Amazon. It is a complement to existing health programs, with the

intention of preventing unnecessary traveling, not always feasible, of

the patient and his family to the town centers.

Registered as OSCIP, Health Expeditions established in 2004 the

Program ‘‘Operating in the Amazon’’ in the region of the Upper Rio

Negro in association with the institutions representing the local

indigenous population and works in coordination of the basic health

care in the region. In order to attend to people who live far from

surgical centers, BHE developed Mobile Surgical Center, adapting to

the special needs, transported and assembled specially for this pur-

pose. It is innovative in Brazil being the first time used by a civilian

organization.

Up to and including September of 2018, BHE completed 41

expeditions with a total of 8003 surgeries and 56,604 consultations.

The larger number of operations are ophthalmology and general

surgery. Other surgeries include pediatric, orthopedic, gynecological

and odontological operations. Also in 2011, BHE completed 7

Expeditions/SOS Haiti to attend the victims of the earthquake which

occurred in January in Haiti, with 359 surgeries and 1407 consulta-

tions from January to October where 78 volunteer professionals

worked in Les Cayes.

In addition to the volunteer doctors, Brazilian Health Expeditions

has the support of other professionals and institutions who help make

this program viable, such as the Ministry of Defense, the Military

Command of the Amazon and the Brazilian Air Force besides

donations of socially responsible companies.

IP-1282

Managing the abdominal wall and hernias

in the military setting

Johnson ECleveland Clinic

Care of injured patients in the modern battlefield setting can be dif-

ficult, and must be achieved often with limited resources. Abdominal

wall defects in the setting of abdominal trauma can be particularly

challenging and require a thoughtful approach. In this presentation,

we will discuss some of the challenges posed to the general surgeon in

the setting of traumatic abdominal injuries sustained in combat. We

will discuss an individualized approach to these patients.

IP-1290

Training and capacity building in Rwanda

Lorenz R, Oppong C, Lechner M, Frunder A, Sedgwick D,

Wiessner R3 ? Surgeons Hernia Center

Introduction: Hernia operations are one of the most common pro-

cedures in General and Visceral Surgery also in Africa. There are a

many possibilities to treat Hernias today. In rural Africa the Bassini

repair seems to be the gold standard until now. Endoscopic equipment

and commercial meshes are frequently not available. The success in

Hernia Surgery is mainly dependent on the skills and experience of

the surgeons. There exist not any evidence on the Surgical Education

in Africa until now.

Methods: Since 2015 the Authors developed in a German-British

collaboration of two humanitarian organizations ‘‘Surgeons for

Africa’’ and ‘‘OperationHernia’’ a first standardized training course

for younger surgeons in Africa. This education program starts with a

2 day theoretical course including anatomical training, lectures and

video demonstrations. The second part includes practical training in

small groups in the OR for 3–5 days. The hands on training includes

inguinal hernia repair with two standardized open operation tech-

niques (SHOULDICE and LICHTENSTEIN Repair) and the use of

local anesthesia. All parts of the training course are continuously

evaluated.

Results: The first two courses of this Basic Hernia Training with 29

participants took place in Rwanda in 2016 and 2017. Formal pre-

ABSTRACTS

123

Hernia (2019) 23 (Suppl 1):S36–S37

course evaluation was conducted to assess the personal surgical

experience of the trainees. We will present the arguments for this

training and all results of the continuous evaluation. At the end of the

training course the majority of the trainees were assessed as able to

perform mesh and pure tissue repair of simple inguinal hernias to an

acceptable standard.

Summary: Because of differences in number of hospitals and sur-

geons, the surgical capacities and patients specifics hernia education

in Africa should be managed and organized completely different. We

have developed a standardized specific hernia basic training course

for Rwanda in Eastern Africa.

IP-1349

Hernia decision making in the non-verbal patientSalvatore Docimo, Jr., MD, MS

123

S37 Hernia (2019) 23 (Suppl 1):S36–S37


Session 11A: Hernia Prophylaxis—AHS Stop the Bulge Campaign


IP-1350

Abdominal wall closure: European hernia society

guidelines

Muysoms FBelgium

.

IP-1351

What’s the matter America? Why not more small bites

and prophylactic mesh?

Jeekel JRotterdam, The Netherlands

.

IP-1352

Parastomal hernia prevention: do we have a consensus?

Montgomery ASweden

.

IP-1353

Why hernia prevention makes sense

Harris HSan Francisco, CA

.

IP-1354

Small bites versus prophylactic mesh: which to use

when?

Fortelny RAustria

.

ABSTRACTS

123



Session 11B: Scientific Abstracts—Hot Topics in Hernia


FP-1158

A new technique for peritoneal flap closure in TAPP:

a prospective randomized controlled trial

Zhu Y, Wang MBeijing Chao-Yang Hospital

Background and purpose: Transabdominal preperitoneal (TAPP)

approach has been widely used for inguinal hernia repair. One critical

and difficult step for the beginners of TAPP is peritoneal flap closure

with laparoscopic suture. To facilitate the suture step, we describe a

new suture method for laparoscopic closure of the peritoneal flap in

TAPP. A prospective Randomized Controlled Trial was carried out to

evaluate the efficacy of the new suture method compared with the

conventional method.

Methods: Eighty patients who presented to our hospital between

September 2017 and February 2017 with primary unilateral inguinal

hernia were randomized into the conventional suture method group

and the new suture group for TAPP repairs. The primary outcome was

the suture time to complete the peritoneal flap closure. Secondary

outcomes included the cases numbers of peritoneum tearing, need of

additional suture and suture line breaking.

Results: The suture time in the new suture method group was sig-

nificantly shorter than that of the conventional group

(715.3 ± 132.4 s vs 840.71 ± 137.9 s, P\ 0.001), furthermore,

there were significant less number of cases of peritoneal tearing in the

new suture method group than in the conventional suture method

group (4 vs 11, P\ 0.01) .

Conclusion: The new suture method is relative easy to learn for the

beginners who performing TAPP procedures as compared with the

conventional method, and less peritoneal tearing is encountered when

using this method for peritoneal flap closure.

FP-1261

Is the International Hernia Collaboration a safe

and effective resource for surgeons?

Bernardi K, Bernardi K, Hope W, Scott J, Shah S, Milton

A, Ko T, Hughes T, Liang MMcGovern Medical School at UTHealth

Introduction: Social media is a growing medium for disseminating

ideas among surgeons. The International Hernia Collaboration (IHC)

is a widely utilized social media platform to share ideas and advice on

managing hernia-related diseases. Our objective was to assess the

safety and effectiveness of advice provided.

Methods: Overall, 60 consecutive, deidentified clinical threads were

extracted from the IHC in reverse chronological order. Three hernia

specialists evaluated all threads for unsafe posts, unhelpful comments,

and mention of established evidence-based management strategies.

Positive and negative controls for safe and unsafe answers were

included in seven threads, and reviewers were blinded to their pres-

ence. Reviewers were free to access all online and professional

resources (except the IHC).

Results: There were 598 unique responses (median 10, 1–26

responses per thread) to the 60 clinical threads/scenarios. The review

team correctly identified all positive and negative controls. Most

responses were safe (96.6%) but many were unhelpful (28.4%). For

16 threads, the reviewers believed there was an established evidence-

based answer, however, only 6 were provided. In addition, 14

responses were considered unsafe, but only 4 were corrected.

Conclusions: The vast majority of responses were considered helpful

(71.4%), however, evidence-based management is typically not pro-

vided, and unsafe recommendations often go uncontested. While the

IHC allows wide dissemination of hernia-related advice/discussions,

surgeons should be cautious when using social media for clinical

advice. Mechanisms to provide evidence-based management strate-

gies and to identify unsafe advice are needed to improve quality

within online forums and to prevent patient harm.

ABSTRACTS

123

Hernia (2019) 23 (Suppl 1):S39–S41

FP-1246

Mesh suture better resists suture pull-through

than small bites surgical technique

Souza J, Scheiber C, Dearth C, Pisano A, Liacouras PWalter Reed National Military Medical Center

Introduction: At its core, incisional hernia is the result of suture pull-

through, which results in early fascial dehiscence and failed healing

of the abdominal wall tissues. The small bites surgical technique

supported by the STITCH trial aims to better distribute forces at the

suture-tissue interface, as demonstrated in a previously reported

porcine tensile force model. Despite this change in technique, the

incidence of incisional hernia remains high. By incorporating mid-

weight polypropylene mesh material into a hollow-bore surgical

suture, mesh suture aims to improve force distribution at the suture-

tissue interface by altering suture design, rather than surgical tech-

nique. Using the porcine model previously described, the efficacy of

mesh suture to resist suture pull-through was compared to the stan-

dard and small bites surgical technique.

Methods: A midline laparotomy was made in 28 porcine abdominal

wall specimens. Samples were randomized into four groups and a

7 cm long segment was repaired using four different combinations of

closure technique and suture material—1 polydioxanone double loop

at 1 cm bites/travel, 1 polydioxanone double loop with 0.5 cm

bites/travel, 2-0 polydioxanone with 0.5 cm bites/travel, and 3.4 mm

mesh suture with 1 cm bites/travel. Using a MTS Bionix Load Frame,

linear force was applied until suture pull-through occurred.

Results: The mean force required for suture pull-through was sig-

nificantly higher for mesh suture (473.3 N), than for the other three

groups (1 polydioxanone 1 cm bites: 324.3 N, 2-0 polydioxanone

0.5 cm bites = 355.4 N, 1 polydioxanone 0.5 cm bites = 386.6 N). A

one-way ANOVA was performed showing a significant difference

between groups (p = 0.009). Post-hoc analysis confirmed the signif-

icance (all p-values\ 0.05).

Discussion/Conclusion: This study validates the role of suture size

and spacing on force distribution at the suture tissue interface, but

suggests that altering suture design may be a more effective strategy

to prevent suture pull-through than altering surgical technique.

FP-1089

Experience with the PINQ-PHONE Telephone

Questionnaire for detection of recurrences

after endoscopic inguinal hernia repair

Bakker W, Roos M, Kerkman T, Burgmans IDiakonessenhuis Utrecht

Background: The PINQ-PHONE is a 4-question telephone ques-

tionnaire designed and validated as a method of follow-up for the

detection of recurrences after laparoscopic inguinal hernia repair. The

aim of this study was to evaluate the PINQ-PHONE by describing our

experience with the questionnaire in a high-volume randomized

controlled trial.

Methods: 5 year follow-up of a randomized controlled trial by means

of the PINQ-PHONE was carried out among 769 patients that

underwent endoscopic totally extraperitoneal (TEP) inguinal hernia

repair. PINQ-PHONE questionnaire outcomes were compared with

the clinical assessment for a recurrence. An experience with the

PINQ-PHONE survey was conducted among the executing

researchers. Furthermore, positive predictive values (PPV) for each

question of the PINQ-PHONE separately and the overall question-

naire were determined.

Results: 52 patients (6.8%) had a positive PINQ-PHONE response

and were invited to visit the outpatient clinic, thus preventing follow-

up visits in 93.2% of included patients. In 2 patients a recurrence was

detected (0.3%). The PPV of question 1 (0.040) and 2 (0.100) was

much lower than that of question 3 (0.222) and 4 (0.286). The overall

PINQ-PHONE’s PPV was 0.057. The PPV of only questions 3 and 4

combined was 3 times higher with 0.183, and no recurrence would

have been missed. The survey among five researchers produced that

the PINQ-PHONE was a user-friendly questionnaire. All researchers,

on average, executed the questionnaire in\ 5 min and considered

questions 3 and 4 as adequate questions for the detection of inguinal

hernia recurrences. Three and 4 out of 5 researchers did not think of

questions 1 and 2, respectively, as adequate questions.

Conclusions: From our experience we recommend to renew the

PINQ-PHONE using only questions 3 and 4. Due to a much higher

PPV more patients can refrain from visiting the outpatient clinic and

still all recurrences are safely detected.

FP-1057

A role for the integrin subunit beta 1 gene in direct

inguinal hernia with family history

Zhu L, Cai M, Li S, Tang JHuadong Hospital Affiliated to Fudan University

Background: Inguinal hernia is one of the most common disorders in

surgery around the world. People with family history of inguinal

hernias have higher risk of developing inguinal hernias. However,

etiology of inguinal hernia heredity still remains unknown. This study

aims to illustrate the characteristics of genetic expression and possible

molecular mechanisms within patients with direct inguinal hernia

(DIH) and positive family history of DIH.

Methods: We performed mRNA sequencing on three cases of DIH

with family history comparing to 3 without family history in blood

and transversalis fascia (TF) respectively after qualified quality check.

The differentially expressed genes (DEGs) between the two groups

were statistical identified. An in-depth analysis using bioinformatics

tools based on the DEGs was performed through using Gene Ontol-

ogy (GO) enrichment, Kyoto Encyclopedia of Genes and Genomes

(KEGG) pathway enrichment, and protein–protein interaction net-

work analysis.

Results: We get 1747 up-expressed and 2694 down-expressed DEGs

using P value\ 0.05 as the cut-off criteria between DIH with family

history or not in blood samples and 1882 up-expressed and 561 down-

expressed DEGs in tissue samples. The phagosome pathway is the

only significant pathway which is down-regulated consistently both in

blood and TF samples. We found 7 hub genes (FCGR3A, TUBA1B,

NCF4, CTSS, HLA-DQA1, ITGB1 and CD14) on phagosome path-

ways. We used reverse transcription-quantitative polymerase chain

reaction (RT-qPCR) to verify the Integrin Subunit Beta 1 (ITGB1)

mRNA expression level. Low expression level of ITGB1 may influ-

ence dysfunction of basement membrane (BM), collagen IV and

leading to the interruption of mechanotransduction.

Conclusions: Our study is the first one to investigate the micro level

of familial direct inguinal hernia. ITGB1 may play a key role in

pathogenesis of direct inguinal hernia with family history. It is pos-

sible to identify high risk inguinal hernia population after genomic

testing for early treatment in the future.

123

S40 Hernia (2019) 23 (Suppl 1):S39–S41

FP-1276

Management of abdominal wall hernias in women

of childbearing age: a qualitative study assessing

surgeon practice

Jafri S, Vitous C, Seven C, Novitsky M, Dimick J, Telem DMichigan Medicine

Introduction: A lack of evidence-based consensus on optimal man-

agement of abdominal wall hernias in women of childbearing age

exists. In this context, we sought to explore surgeon practice and

understand the factors impacting surgeon decision-making in this

patient population.

Methods: We conducted 21 semi-structured, qualitative interviews

with practicing surgeons in a large statewide quality collaborative.

Surgeons were diverse with respect to demographics, training, and

institutional settings. A clinical vignette was designed to capture

surgical approaches and factors motivating decision-making for

repairing abdominal wall hernias in women of childbearing age.

Through thematic analysis, we located, analyzed, and reported pat-

terns within the data.

Results: Thematic analysis demonstrated a wide variety of patterns

concerning operative approaches to women of childbearing age.

Regarding family planning, 57% (n = 12) of surgeons indicated

desired future pregnancy would impact operative timing and

approach, while 43% (n = 9) stated it would not. Three major themes

that emerged during analysis of scenarios where surgeons altered their

approach in women of childbearing age included: (1) the majority of

surgeons demonstrated a preference to defer an operation until the

completion of childbearing, even for patients desiring repair. (2)

Surgeons described the necessity of a thorough discussion of options

with the patient and would recommend deferring the operation,

though would ultimately concede to patient preference. (3) Surgeons

described variability in mesh utilization. Gender, generational, and

practice location differences did not motivate decisions.

Conclusion: Marked polarization in the approach to women of

childbearing age with abdominal wall hernias exists. Nearly half of

surgeons do not account for future childbearing when managing

abdominal wall hernia. Conversely, the remainder exhibit bias

towards deferring an operation despite patient preferences. These

findings highlight the need for patient-shared decision-making aids to

stimulate unbiased discussion and ensure patients are provided uni-

form information when deciding on management options.

FP-1122

Prevalence of posttraumatic stress disorder (PTSD)

in patients with an incisional hernia

Alkhatib H, Tastaldi L, Fafaj A, Krpata D, Petro C,

Rosenblatt S, Rosen M, Prabhu ACleveland Clinic Foundation

Introduction: Despite good technical outcomes of surgery, some

hernia repair patients report constant concern about having a hernia

recurrence requiring additional repair. These feelings of chronic

anxiety and hyper-vigilance are similar to those experienced by

individuals who have Posttraumatic Stress Disorder (PTSD). We

aimed to investigate the prevalence of PTSD in patients with an

incisional hernias presenting for evaluation at our institution.

Methods: All patients scheduled for clinic visit due to an incisional

hernia at our institution were eligible for participation. PTSD was

screened using the PCL-5 checklist for DSM-5. Patient-reported

quality of life and pain scores were also assessed using validated tools

(HerQLes and PROMIS Pain Intensity 3a survey, respectively). Other

potential risk factors were collected and analyzed.

Results: A total of 131 patients were enrolled (mean age 57.5 ± 11.4,

53% females, and with a median of 3 prior abdominal operations and

one prior hernia repair). 8% had been in the military and 2% reported

deployments. PTSD prevalence was 32% [95% CI 24%–40%]. Out of

the 42 patients screening positive (PTSD ?), 72% related their

symptoms to their previous operations and the resulting complications

while 12% related it to the hernia itself. PTSD ? patients had lower

quality of life scores (39.4 ± 7.4 vs. 55 ± 15.2, P\ 0.001), and

higher pain scores (54.2 ± 9.1 vs. 44.2 ± 10, p\ 0.001). The

number of prior abdominal surgeries and hernia repairs was also

significantly higher in the PTSD ? subgroup, as well as a history of

open abdomen.

Conclusion: Almost one-third of patients undergoing hernia repair

report symptoms of PTSD that are often associated with a worse

perception of the disease and history of multiple prior abdominal

surgeries and hernia repairs. The influence of these findings on

patient’s recovery is unknown. Hernia repair may require a multi-

disciplinary team addressing these significant issues to ensure optimal

care for such patients.

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Hernia (2019) 23 (Suppl 1):S39–S41 S41


Session 12A: AHSQC Panel Session: Long Term Follow Up and Registry-Based ClinicalTrials


FP-1230

Hybrid robotic transversus abdominus release

has shorter length of stay compared to open transversus

abdominus release: an AHSQC analysis

DeMare A, Halka J, Vasyluk A, Iacco A, Janczyk RBeaumont Health

Background: Open Transversus Abdominus Release (oTAR), tradi-

tionally necessary for the repair of large ventral hernias, is associated

with a substantial hospital length of stay (LOS). Robotic Transversus

Abdominus Release (rTAR) offers the benefits of minimally invasive

surgery (MIS) with decrease LOS vs. oTAR, but this technique may

be inadequate for large, complex hernias. In Hybrid Robotic

Transversus Abdominis Release (hrTAR), limitations of MIS are

overcome by first performing a robotic flap dissection and subse-

quently opening the hernia sac. This modification allows for large

mesh placement, linea alba medialization, secure closure of wide,

complex fascial defects, and resection of the hernia sac and skin. Our

aim was to compare short-term outcomes between hrTAR and oTAR

patient cohorts.

Methods: Multi-institutional data of patients who underwent hrTAR

or oTAR were collected by utilizing the Americas Hernia Society

Quality Collaborative (AHSQC) between 2016 and 2018. Propensity

score matching was used to compare hrTAR to oTAR cohorts,

specifically focusing on median LOS.

Results: In total, 95 hrTAR and 285 oTAR patients met our inclusion

criteria. Patient and hernia characteristics were similar between

groups with a median hernia width of 12 cm. Median LOS [in-

terquartile range (IQR)] was significantly decreased for the hrTAR

cohort [3 days (IQR 3)] vs the oTAR cohort [5 days (IQR 3),

P\ 0.001]. Surgical site occurrence (SSO) occurred less frequently

in the hrTAR group [5% vs 15%, P = 0.015], but there was no sig-

nificant difference in SSI or SSO requiring procedure interventional

between groups. There were also no differences between groups in

30-day rates of readmission, reoperation, or major complications.

Conclusion: hrTAR has significantly lower LOS and incidence of

surgical site occurrences compared to oTAR.

IP-1355

Is mechanical fixation needed in open retromuscular

ventral hernia repair?

Pierce RVanderbilt University Medical Center

.

IP-1356

Telescopic dissection versus balloon dissection

in laparoscopic TEP repair: a registry-based

randomized controlled trial

Tastaldi LCleveland Clinic

.

FP-1235

Assessing outcomes of myofascial release using

the AHSQC

Tenzel P, Bilezikian J, Israel I, Appleby P, Hope WNew Hanover Regional Medical Center

Myofascial release techniques at the time of complex hernia repair

allow for tension free closure of the midline fascia. Two of the main

techniques used include the external oblique release (EOR), which

can be performed open or endoscopically, and the transverus

abdominus release (TAR). Each technique has their reported advan-

tages and disadvantages but there have been few comparative studies.

The purpose of this project was to compare outcomes of these

myofascial release techniques.

Data from the Americas Hernia Society Quality Collaborative was

queried on 5/12/2018. All patients undergoing open incision hernia

repair with an open or endoscopic external oblique release or a

transversus abdominus release were evaluated and compared with

outcomes including hernia recurrence, quality of life, and 30 day

wound complications.

ABSTRACTS

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Hernia (2019) 23 (Suppl 1):S42–S43

There were 3109 patients that met inclusion criteria of undergoing

open repair of incisional hernia with an EOR or TAR and 501 patients

that met inclusion criteria of undergoing open or laparoscopic

external oblique release. There were no differences in outcomes

comparing EOR and TAR for hernia recurrence, QOL, or 30 days

surgical site infection (SSI) rate. The EOR had a significantly higher

rate of surgical site occurrences (SSO’s) compared to TAR (p\ 0.05)

however this did not result in an increase in procedure intervention for

the SSO. There were no differences in outcomes comparing open and

laparoscopic EOR for hernia recurrence, quality of life, or 30 days

surgical site infection (SSI) rate. The laparoscopic EOR had a sig-

nificantly higher rate of surgical site occurrences (SSO’s) compared to

the open EOR (p\ 0.05) however this did not result in a significant

increase in procedural intervention for the SSO.

Equivalent outcomes were achieved using the open and endo-

scopic EOR or TAR techniques in open repair of incisional hernia. All

techniques offer good outcomes and are important adjuncts in the

repair of complex incisional hernias.

FP-1173

Integration and implementation of patient recorded

outcomes (PROS) into clinical practice

Kozak G, Nathan S, Messa C, Thrippleton S, Broach R,

Fischer JHospital of the University of Pennsylvania

Introduction: Patient reported outcomes (PROs) quantify self-re-

ported perceptions of health and quality of life and aid in capturing

the full effect of disease burden and interventions. Implementation of

PROs can be a challenge with respect to work flow and patient survey

burden. We report the strategy and process associated with successful

implementation of a disease specific questionnaire over a 30-month

period.

Method: A retrospective chart review from September 2016 to

August 2018 was conducted. All ventral hernia (VH) encounters

(n = 714) for a single surgeon were assessed and analyzed at 6-month

intervals. Encounters were excluded if VH was not the primary

diagnosis or if the visit fell within 2 weeks of another survey visit. We

monitored the implementation process by educating office members,

identifying appropriate patients, and eventually integrating the survey

into the EMR.

Results: During a 30-month implementation process, 35/64 (55%),

42/48 (88%), 54/61 (89%), 51/56 (91%), and 63/71 (89%)

(p\ 0.0001) pre-surgery surveys were completed for five consecutive

6-month intervals. The post-surgery questionnaire completion rate

showed similar trends; 11/51 (22%), 43/68 (63%), 48/53 (91%), 58/70

(83%) to 55/70 (79%) (p\ 0.0001) for the same five consecutive

6-month windows. During this time point, 461 of 612 (75%) surveys

were completed and the total questionnaire administration rate

increased 210% (from 40% to 84%, p\ 0.0001). A 210% increase in

successful survey administration was released through the process.

Conclusions: The administration of PROs began by reading survey

questions directly to patients and has evolved to an integrated,

automatic, real-time scoring questionnaires embedded in the EMR.

The successful implementation of PROs was four-fold: office and

staff engagement/education, optimization of work flow, identification

of proper patients, and electronic integration of the survey. PROs can

be administered consistently and effectively in clinical practice

through a process-driven strategy that focuses on healthcare stake-

holder engagement and education.

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S43 Hernia (2019) 23 (Suppl 1):S42–S43


Session 12B: Scientific Abstracts—Parastomal Hernia & Hiatal Hernia


FP-1233

Hiatal hernia and gerd: an indication for conversion

from sleeve gastrectomy to Roux-En-Y gastric bypass

Allen D, Howell R, Cherasard P, Hall K, Barkan A,

Brathwaite CNYU Winthrop Hospital

Introduction: For patients with hiatal hernia (HH) or gastroe-

sophageal reflux disease (GERD), sleeve gastrectomy (SG) has been

shown to exacerbate GERD, prompting some patients to be converted

to Roux-en-Y gastric bypass (RNY). This study presents the incidence

and short-term outcomes of SG to RNY conversion in patients with

HH and GERD.

Methods: Our prospectively-maintained database was retrospectively

reviewed for patients with HH and GERD who underwent SG to RNY

conversion from January 2007 to December 2017 at a Metabolic and

Bariatric Surgery Accreditation and Quality Improvement Program

Center of Excellence.

Results: 32 patients underwent SG to RNY conversion, and 18 were

eligible for inclusion. Sixteen patients were female (89%). Mean age

was 46 years (range 27–63), body mass index 42.8 (range 29–64), and

weight 267 lb (range 180–476). Co-morbidities included: hyperten-

sion (n = 9; 50%), obstructive sleep apnea (n = 8; 44%),

osteoarthritis (n = 8; 44%), and diabetes (n = 2; 11%). 44% of

patients had GERD prior to SG and the remaining 56% were noted to

develop de novo GERD prior to RNY conversion; p = 0.0003, Chi

square). Mean time between initial SG and conversion to RNY was

35 months (range 1–87). All conversions were performed minimally-

invasively (56% laparoscopic, 44% robotic). HH was concomitantly

repaired in 6 patients (33%; 1 synthetic mesh, 5 suture cruroplasty).

Mean length of stay was 3.2 days (range 2–9). 30-day events inclu-

ded: 1 reoperation (5.6%), 2 readmissions (11%), 4 complications

(22%), and no mortalities. Complications were classified using the

Clavien-Dindo grading system: 1 grade II, 2 grade IIIa, and 1 grade

IV.

Conclusion: Prior to bariatric surgery, there should be continued

vigilance to identify HH and patient counseling regarding the risk of

worsening or de novo GERD following SG. RNY may be the primary

procedure of choice in the setting of HH and GERD to decrease the

likelihood of requiring revisional surgery.

FP-1247

Prophylactic mesh augmentation for prevention

of parastomal hernia

Foster A, Fox S, Love W, Warren J, Carbonell A, Cobb W,

Pearson D, Allen J, Dean KGreenville Health System

Parastomal Hernia (PSH) occurs in 50–80% of stoma patients and

causes significant morbidity. There is no optimal PSH repair tech-

nique, and recurrence rates remain high. Prophylactic mesh

augmentation (PMA) decreases PSH incidence without increasing

complications.

A retrospective review was performed of patients undergoing

PMA during end stoma creation between Jan 2015 and Jul 2018. 24

patients were treated with stapled transabdominal ostomy reinforce-

ment with retromuscular mesh (STORRM), and the remainder with

standard retromuscular keyhole mesh. All but two patients received

large-pore polypropylene mesh reinforcement. Primary outcome was

development of PSH. Secondary outcomes are surgical site infection

or occurrence (SSI or SSO).

55 patients were included: 32 end colostomy, 9 end ileostomy, 1

loop colostomy, 12 ileal conduit and 1 colonic diversion/urostomy.

Mean age was 60 years. One-third had significant comorbidities:

diabetes (21.8%), COPD (9%), smokers (30%), and obesity

(BMI[ 30; 30.9%). Fifteen patients had a concurrent ventral hernia

repair. Stoma site-specific SSI occurred in 4 (7.3%) patients, and SSO

in 13 (23.6%). Eight patients required procedural intervention, and

one required mesh explantation. At mean follow up of 24 months,

12.7% had a clinical or radiologic PSH. 23 patients (41.8%) were able

to be contacted for phone survey, and 7 additional patients (12.7%)

reported symptoms of PSH (pain, bulge, pouching difficulty, pro-

lapse). Recurrence rate was lower with STORRM, with only 1

documented recurrence (4.2% vs 19.4%; p = 0.94), though not sta-

tistically significant.

Retromuscular prosthetic mesh augmentation at the time of per-

manent stoma creation significantly reduces the risk of developing a

parastomal hernia.

ABSTRACTS

123

Hernia (2019) 23 (Suppl 1):S44–S45

FP-1053

A retrospective review with prospective follow-up of 85

consecutive patients treated with Miromesh� for hiatal

hernia repair

Gillian G, Bansal DVirginia Heartburn and Hernia Institute

Introduction: The failure rate for laparoscopic repair of large hiatal

and paraesophageal hernias is commonly reported to exceed 10%.

These failures are often a result of a breakdown of the integrity of the

primary tissue closure of the hiatus. Efforts to reinforce these closures

with permanent and biologic/absorbable meshes have shown promise

in some series. Unfortunately, the techniques and materials utilized

are far from standardized and the complications can be severe. A

simplified and effective biologic mesh cruroplasty is demonstrated.

Methods: 85 consecutive patients undergoing laparoscopic Nissen

fundoplication for hiatal (62) or paraesophageal (24) repairs had their

cruroplasty reinforced with a novel biologic prosthetic derived from

perfusion decellularization of porcine liver (MiroMesh�). After pri-

mary hiatal closure the mesh was secured as an onlay patch with

permanent suture.

Results: The mesh caused no postoperative complications or delays in

diet advancement. 73 (85.9%) of the subject were available for an

IRB approved structured interview 1.3 years (range 0.5–1.8) months

from the time of surgery. Preoperative DeMeester score was 18.9 (SD

14.9) and the GERD-HRQL was 27.7. This cohort reported a drop in

GERD-HQRL scores to 7.1, a satisfaction rate of 95% and no

endoscopic/surgical reinterventions. Only 9% of these patients had

utilized a PPI at any time in the preceding 3 months.

Conclusion: MiroMesh� placement to reinforce the hiatal repair

during laparoscopic Nissen fundoplication was easily accomplished

and has not resulted in any complications to date. Excellent GERD-

HRQL scores 1.3 years after surgery suggest that a durable repair has

been achieved to this point. This information should encourage sur-

geons seeking to reduce recurrent hiatal hernias in their own

practices. It is hoped that this technique will show a reduction in

recurrent hiatal hernias over an extended follow up and benefit a

larger group of.

FP-1153

Large hiatal hernia with the upside-down stomach.

What is the best way?

Klobusicky P, Feyerherd P, Hilfinger U, Hoskovec DHelios St. Elisabeth Hospital

Introduction: The upside-down stomach (UDS) is an extreme form

of a hiatal hernia (HH) and of gastric organoaxial volvulus in a

supradiaphragmatic hernia sac. The aim of this observational study

was to analyze the results of patients with large hiatal hernia and UDS

after surgical closure on the laparoscopic way with or without fun-

doplication. The laparoscopic repair of such hernias is a therapeutic

option, performed mostly in centers by experienced surgeons.

Methods: From 2011 to 2018, 21 patients, with giant HH and UDS,

divided in two groups (10 and 11 Pts), were primarily treated by

laparoscopic surgery at the surgical Department of Helios St. Elisa-

beth Hospital in Bad Kissingen. First group was treated by

laparoscopic suture-based hiatoplasty, with the second group it was

accompanied by dorsal hemifundoplication. Demographic data,

operations data morbidity and mortality were recorded prospectively.

Follow-up was conducted by means of a questionnaire via phone

interview.

Results: In the period of 2011–2018, 21 patients (19$2#) were

diagnosed with a symptomatic giant HH and UDS at our clinic. There

were no intraoperative complications and no conversions. Postoper-

ative complications occurred in one patient (4.7%). Median

postoperative stay was 5 days (2–17). The median follow-up was

29 months by means of a questionnaire via a phone interview. No

significant difference between the two groups, based on the postop-

erative complications and recurrence, was recorded. There were two

subclinical axial recurrences recorded, one per group and no

reoperations.

Summary: Laparoscopic suture-based hiatoplasty of large HH and

UDS is a relatively safe method with significant long-term efficacy in

terms of symptoms control and quality of life. Additional use of

dorsal hemifundoplication does not seem to be necessary.

FP-1166

Mesh salvage following deep surgical site infection

Siegal S, Morrell D, Orenstein S, Pauli EOregon Health and Science University

Introduction: Following herniorrhaphy, deep surgical site infections

with mesh involvement (dSSI-MI) traditionally necessitate mesh

removal, putting patients at risk for hernia recurrence. There is no

consensus about managing dSSI-MI with salvage strategies. We

describe our outcomes following dSSI-MI at two high-volume hernia

centers.

Methods: A retrospective review of hernia repairs complicated by

dSSI-MI with subsequent salvage attempt was undertaken. Outcome

measures included duration of antibiotic use, recurrent dSSI-MI, need

for mesh excision, postoperative complications, and hernia

recurrence.

Results: 13 patients underwent attempted mesh salvage (female = 8,

mean age = 61, mean BMI = 31.4). 46% had prior mesh repairs and

23% had prior SSI. Twelve underwent open ventral or parastomal

repair (10 sublay and 1 onlay macroporous polypropylene, 1 sublay

biosynthetic poly-4-hydroxybuterate). Six cases required concomitant

bowel surgery. Five infections resulted from GI tract leak (3 ostomy

complications, 1 colonic anastomotic leak, and 1 gastric perforation).

92% required reoperation for wound debridement. Seven received

negative-pressure wound therapy (NPWT, average 29 days). Mesh

was left intact in 83%, while 17% required less than 0.01% of mesh

area excision during salvage therapy. All patients received antibiotics

(average 21.4 days). There was one pulmonary embolism, one epi-

sode of septic shock, two prolonged mechanical ventilations, three

blood transfusions and one mortality as the result of a stroke. With a

median follow up of 16 months, there were two recurrent SSIs and

one new parastomal site hernia managed non-operatively.

Conclusion: Mesh salvage without complete explantation is feasible

following dSSI-MI, with a low rate of recurrent hernia formation or

long-term infections. Salvage attempts were undertaken primarily in

patients with retromuscular macroporous polypropylene, suggesting

that repair type and mesh choice influence the decision-making and

ability for salvage. This cohort did require significant postoperative

care (re-operations, prolonged antibiotics, NPWT) and had a high rate

of additional morbidities.

123

S45 Hernia (2019) 23 (Suppl 1):S44–S45


Session 13: Spectacular Cases (Panel Session)


FP-1137

Chronic groin pain leading a 22-year old to disability.

What now?

Fogaca de Barros P, Tastaldi L, Favacho B, Freitas

do Amaral P, Hernani B, Altenfelder Silva R, Chen D, Roll

SSanta Casa de Sao Paulo School of Medical Sciences

A 22 y/o male who presented to Hernia Clinic due to bilateral chronic

postoperative inguinal pain (CPIP). Past surgical history is positive

for an elective, open, bilateral inguinal hernia repair with mesh due to

a small symptomatic left inguinal hernia and an asymptomatic right

inguinal hernia. Surgery was complicated by severe neuropathic pain

resulting in impairment in quality of life and leading the patient to be

on worker’s compensation for the past 2 years. CPIP was initially

managed by pain specialists, and nerve blocks provided only minimal

and transient relief. Sequentially, patient has undergone an open mesh

removal in the right side with attempted neurectomy that, unfortu-

nately, was unsuccessful as the operative report describe that the

nerves could not be located due to exuberant scar tissue. Bilateral

CPIP persisted (VAS 10 R and VAS 6 L) associated with difficulty for

ambulation (walking on crutches) and major depressive disorder.

Dermatomal mapping was consistent with bilateral involvement of

the IIN, IHN and GFN nerves and patient was offered a bilateral triple

neurectomy with removal of remaining mesh.

In August 2018, a bilateral laparoscopic neurectomy of the GFN

and bilateral open neurectomy of IIN and IHN, mesh removal on the

left side and repair of resultant recurrence through a Shouldice

approach was performed. Intraoperatively, it was noted that technical

failure contributed to the CPIP, particularly with several permanent

sutures fixating mesh in the medial aspect and entrapping the IHN.

Recovery was uneventful, and patient was discharged on POD2. At

30-day follow-up, patient reports that is pain- free and the der-

matomal mapping is consistent with bilateral triple neurectomy.

We believe this case provides the opportunity to discuss quality

improvement in indications for hernia repair and hernia repair tech-

nique. Also, it is an excellent opportunity to comprehensively address

prevention, diagnosis and management of CPIP.

FP-1044

Lateral abdominal wall dehiscence after component

separation

DeVitis J, Banks-Venegoni A, Conway R, Wright GSpectrum Health

Background: Lateral abdominal wall hernias are an uncommon yet

devastating complication of the component separation technique for

repair of ventral hernias. There is a paucity of literature describing

repair techniques and outcomes for such complications. In this case,

we present a potential algorithm for operative strategy to deal with

such complications.

Case: 70-year-old male with a past medical history of diabetes mel-

litus, former tobacco abuse, and surgical history of multiple ventral

hernia repairs and chronic mesh/wound infections presented to the

Advanced Hernia Clinic for a recurrent infection of his mesh. He was

taken to the operating room for open ventral hernia repair with

explantation of prior mesh, external oblique release on the left,

implantation of biologic mesh, and placement of a negative wound

pressure system. On post-operative day 4, the patient was noted to

have a fascial dehiscence with evisceration of intra-abdominal con-

tents. He was subsequently taken back to the operating room for

exploration and found to have a 13 cm defect at the point of the

external oblique release. Botulinum toxin injections were applied to

the oblique muscles to facilitate delayed closure. A Whitman patch

was eventually placed for segmental closure of the dehiscence. The

repair was completed on post-operative day 22 using a combined

technique of underlay Phasix mesh, followed by prolene mesh sutures

for primary closure of the defect. The repair was effective and has

thus far shown no signs of recurrence despite his many co-morbidities

and infections.

Conclusion: Lateral abdominal wall defects present a unique chal-

lenge for reconstructive surgeons. In this case, we present a

management strategy of acute fascial dehiscence after component

separation by use of botulinum toxin injection, the Whitman patch,

and the mesh suture technique.

FP-1237

Robotic TAPP inguinal hernia repair: a palliative

approach in a patient with sepsis and possible

pneumatosis intestinalis

Zumba O, Scholer A, Mazpule G, Pereira S, Rosenstock AHackensack University Medical Center

The use of robotics to perform minimally invasive surgery has

emerged as a viable option for most general surgery procedures. The

robotic platform offers robust repair with minimal complications,

ABSTRACTS

123

Hernia (2019) 23 (Suppl 1):S46–S48

most notably for inguinal hernias. The utilization of the robot for

Transabdominal Preperitoneal (TAPP) inguinal hernia repair allows

for correction of large defects by resection of the hernia sac and mesh

placement. However, this repair method is usually confined to the

elective setting due to the requirements of robotic surgery, including:

the use of CO2 for insufflation, general anesthesia, and possible

increased OR time. Here, we present the surgical video of a 77-year-

old-male with a chronically incarcerated large inguinal hernia that

resulted in a small bowel obstruction and sepsis, thought to be sec-

ondary to findings of pneumatosis intestinalis on imaging. This video

shows a robotic TAPP inguinal hernia repair as a palliative procedure

in a critically ill patient. Specifically, the demonstration of incomplete

resection of this patient’s large hernia sac with anticipation of a large

postoperative seroma, is a unique approach in this emergent situation.

As a result of this procedure, this patient with multiple comorbidities

and high surgical risk for morbidity and mortality, had both resolution

of his small bowel obstruction and therapeutic repair of his chronic

inguinal hernia.

FP-1037

Repair of spontaneous intercostal hernia via open

transthoracic extrapleural approach

Schlosser K, Maloney S, Augenstein VCarolinas Medical Center

Introduction: Spontaneous intercostal hernias have been described in

the literature, but mesh fixation and rib re-approximation is chal-

lenging, with paucity of mesh fixation sites. Here we discuss the

repair of a spontaneous intercostal hernia via transthoracic

extrapleural approach.

Case report: A 66-year-old male presented with left flank bulge and

discomfort. Patient had a history of hypertension, anxiety, chronic

cough, obesity (BMI 31.4 kg/m2), open inguinal hernia repair and

laparoscopic cholecystectomy, and no history of chest wall trauma.

He described a coughing fit with sudden sharp flank pain, ecchymosis

and bulge. A soft bulge at the anterior axillary line between ribs nine

and ten was easily reducible. CT scan revealed disruption of internal

intercostal muscle and separation of ribs (7.9 cm on left vs. 2.9 cm on

right). Due to persistent discomfort, he was taken for open repair of

left intercostal hernia with preperitoneal mesh, open reduction and

internal fixation of adjacent ribs. Intraoperative findings included an 8

by 15 cm hernia. A preperitoneal plane was developed for placement

of a 33x25 cm synthetic mesh secured with transabdominal and

transthoracic sutures. Titanium plates were placed on ribs nine and

ten and secured with screws. Six #5 steel wires were driven through

the ribs and plate holes, and the intercostal gap was reapproximated

by twisting the wires. A Jackson-Pratt drain was placed, tissues were

closed by layers, a liposomal bupivacaine intercostal block was per-

formed, and an incisional VAC was placed. The patient did well

postoperatively and was discharged on postoperative day 4.

Discussion: The repair of intercostal flank hernias is poorly described

in the literature. Approach requires integration of complex hernia

repair as well as familiarity with rib fixation techniques. Here we

describe repair of intercostal flank hernia with preperitoneal mesh

placement and open reduction and internal fixation of ribs.

FP-1176

Abdominal wall reconstruction in a patient

with an incomplete anterior pelvic ring

Fafaj A, Svestka M, Wood H, Mesko N, Billow D, Petro C,

Krpata D, Rosen M, Prabhu ACleveland Clinic

Purpose: Suprapubic incisional hernias can be challenging to repair

given the need for reliable fixation which usually involves the pubis.

Bony defects in the pelvis make it difficult to achieve appropriate

mesh overlap and fixation, posing a major challenge for the recon-

structive surgeon. Our multidisciplinary approach to repair a large

suprapubic hernia in the setting of an incomplete anterior pelvic ring

is presented step-by-step in this video.

Materials and method: A 64-year-old male with a prior history of

osteomyelitis requiring resection of the pubic symphysis and rami

presented to hernia clinic with a large suprapubic incisional hernia.

Past surgical history included prostatectomy, right inguinal hernia

repair and cystectomy with urinary diversion by means of an Indiana

Pouch, which required revision due to incontinence. Operative strat-

egy was planned with the collaboration of Orthopedic and Urology

specialists; elective hernia repair with combined reconstruction of the

anterior pelvic ring and revision of the Indiana pouch was offered.

Results: An open, bilateral posterior myofascial release was per-

formed followed by revision of the urinary diversion channel. The

anterior pelvic ring was reconstructed with a four-hole dynamic

compression plate which was anchored in place by two 6.5 mm

cannulated screws with the aid of guide pins and fluoroscopy. A large

piece of synthetic mesh was placed as a sublay and fixated with bone

anchors and into the metal plate. Patient recovery was uneventful and

he was discharged on postoperative day 8.

Conclusion: A suprapubic hernia associated with a bony defect in the

pelvis is a challenging clinical scenario. Reconstruction was achieved

with good short-term results by a multidisciplinary team.

FP-1097

Just your ‘‘Routine’’ open inguinal hernia repair

Maloney S, Schlosser K, Heniford B, Augenstein VCarolinas Medical Center

Introduction: Inguinal hernia repairs are one of the most common

general surgery procedures, with an incidence of 28 per 100,000 in

the United States. Incarcerated or strangulated hernias are usually

repaired open. Paratesticular liposarcoma is a very rare disease (161

cases reported in the literature) which has the potential to present like

an inguinal hernia. Based on the rarity of the disease, the role of

treatment outside of radical excision (radiotherapy or chemotherapy)

is not well established.

Case report: A 68-year-old gentleman presented to clinic with a

4-month history of an increasing right inguinal hernia. According to

the patient, he had minimal discomfort, and the hernia had progressed

from reducible to incarcerated. He had no previous intraabdominal

surgery. After appropriate clearance and discussion of risks and

benefits, the patient was taken to the operating room. The scrotal

contents would not reduce under anesthesia therefore open approach

was implemented. After dissection it was noted that scrotum con-

tained a 14x9 cm mass starting at the inguinal canal. The mass was

sent to pathology and found to be a low grade liposarcoma of the cord

(Grade 1/3; Stage pT2b pNX). Urology was unavailable to perform an

oncologic resection. The inguinal floor was reinforced with mesh.

Postoperative MRI revealed another mass extending from the inguinal

canal down into the scrotum. The patient underwent a radical

123

S47 Hernia (2019) 23 (Suppl 1):S46–S48

orchiectomy and compartment resection 3 weeks later. Despite neg-

ative margins, the patient had one recurrence requiring another

excision 11 months after initial surgery. He was recently seen with

imaging and does not have cancer or hernia recurrence.

Conclusion: We present a gentleman with an apparent incarcerated

inguinal hernia which at the time of surgery was identified to be a

liposarcoma requiring subsequent oncological resection. Although

rare, surgeons should keep paratesticluar liposarcoma in the differ-

ential with incarcerated inguinal hernias.

123

Hernia (2019) 23 (Suppl 1):S46–S48 S48


Session 14: Special Technique in Ventral and Inguinal Hernia


IP-1357

The laparoscopic onlay repair: why you should consider

it

Totti Cavazzola LBrazil

.

IP-1358

Minimally open sublay technique (Milos)

Reinpold WGermany

.

IP-1359

A successful approach to managing enterocutaneous

fistula

Harold KMayo Clinic

.

IP-1360

Extraperitioneal minimally invasive repair options

Claus CJacques Perissat Institute/Positivo University

.

IP-1292

A new approach to laparoscopic bilateral hernia repair:

the BTOM

Castagneto G, Raimondi SSanatorio Guemes

Since the early description of the TAPP technique for the repair of

inguinal hernias, few modifications have been proposed. The recur-

rence rate of TAPP hernioplasty has been reported between 1 and 5%.

Studies on the causes of recurrence have shown that its etiology is

multifactorial, however they agree that most recurrences of TAPP

technique are direct hernias. Another situation that has attracted

attention is postoperative pain and its relationship with the type of

fixation. We will present our BTOM technique as a safe and feasible

alternative to reduce the number of recurrences and chronic postop-

erative pain in TAPP bilateral hernioplasties.

IP-1283

Intraperitoneal polypropylene in giant ventral hernia

Brandi CHospital Italiano de Buenos Aires, Argentina

Purpose: Show our experience and technique of repairing giant

ventral hernias by placing intraperitoneal polypropylene mesh.

Methods: retrospective descriptive study of a prospective cohort of

patients undergoing elective IH repair using intraperitoneal uncoated

PPE mesh at the Department of General Surgery of a high complexity

University Hospital.

Results: Between January 1992 and December 2013, 695 IH repairs

were performed using intraperitoneal uncoated PPE mesh. The

omentum was placed between the mesh and bowel in 507 patients

(73%). In 188 patients (27%) it was not possible to place the omentum

between the mesh and bowel; therefore, in 69 patients (9.92%) the

PPE mesh was placed over the bowel, whereas in 119 patients

(17.12%) a Vicryl_ mesh was placed between the bowel and PPE

mesh. Six hundred and seventy-eight (97.5%) IH repairs were open

whereas 17 (2.5%) were laparoscopic. Postoperative complications

consisted of seroma (5.9%), hematoma (4.3%), wound infection

(4.8%), and mesh infection (4.0%). Recurrence of IH occurred in 52

patients (7.4%) after a mean follow-up of 59 months. Four (0.5%)

patients required additional surgery due to intestinal occlusion. Nei-

ther acute nor chronic ECFs were encountered during follow-up in

695 patients.

Conclusion: Based on these results, the placement of intraperitoneal

uncoated PPE mesh for elective IH repair might be a safe procedure.

Posters

ABSTRACTS

123


Posters


P-1004

Postoperative-treatment following open incisional

hernia repair: a survey and a review of literature

Paasch C, Strik M, Anders SHELIOS Klinikum Berlin-Buch

Introduction: Incisional hernias of the abdominal wall are frequent

complication after laparotomy (9–20%). Open incisional hernia repair

with sublay mesh placement (SMP) on the posterior rectus sheath is

described as being a sufficient method for repairing incisional hernia.

In order to ensure wound healing and to therefore prevent recurrence,

carrying an abdominal binder (AB) or a pressure dressing (PD) and

physical rest for a certain time is the common postoperative recom-

mendation, though the evidence for post-operative treatment is low.

Hence, we conducted a survey to reveal the different recommenda-

tions given by surgical departments (SD).

Methods: We conducted a survey among 65 German SDs of the XXX

Hospital Group. The SDs were interviewed about the number of open

incisional hernia repair with SMP in the time frame of 2013–2014, the

known recurrence rate (RR), their recommended prescription of the

AB/PD and the time of physical rest.

Results: The head physicians of 48 surgical departments answered the

questionnaire. The survey revealed 42 different recommendations of

postoperative-treatment. The majority of the SDs advices 4 weeks

(20.5%) of physical rest and no prescription of the AB (29.5%). No

correlation between the known RR and the duration of physical rest

was detected. No head physician’s prescribes a PD.

Conclusions: Due to our findings we assume that a short period of

physical rest is a considerable postoperative treatment following an

open incisional hernia repair with SMP. By reducing the individual

incapacity for work and immobility this would have a social-eco-

nomic impact. The use of a PD may prevent seroma formation.

Further investigations with randomized clinical trials are mandatory

to support our hypothesis.

https://doi.org/10.1016/j.ijsu.2018.04.014

P-1005

Comparison of polypropylene mesh and poly-L-lactic

acid polypropylene mesh for laparoscopic total

extraperitoneal (TEP) inguinal hernia repair

Agca B, Iscan AUniversity of Health Sciences, Fatih Sultan Mehmet Training

and Research Hospital, General Surgery Department

Introduction: When the results of the laparoscopic groin repair are

examined, it is suggested that the cause of chronic agrin and foreign

tissue sensation is polypropylene patches and patch-fixing products.

In this study, polypropylene patch (Prolene� Ethicon) and poly-L-

Iactik-acid polypropylene patch (4DMesh�-CousinBiotech) were

compared in laparoscopic total extraperitoneal hernia repair.

Materials and methods: Between January 2014 and December 2017,

a total of 357 patients between 20 and 80 years of age were enrolled

in the Istanbul Fatih Sultan Mehmet Training and Research Hospital.

The data of the patients were retrospectively analyzed and the results

were compared between group 1 (polypropylene patch) and group 2

(poly-L-Iactik -acid-polyproplene patch). Surgeons, complications,

patch stabilizers, postoperative pain and long-term outcomes were

examined retrospectively.

Results: Group 1 and 2 were 192 (66.4%) and 97 (33.6%), respec-

tively. Operative periods were 48.3 min in group 1 and 38.4 min in

group 2 and less statistically significant in group 2 (p\ 0.05). There

was no difference in complications (Group 1/2: 32/20 p: 0.1). Patch

fixation was observed to be less in group 2 (Group 1: 4.1 vs 2.3 p:

0.001). There was no difference in pain after surgery (Group 1: VAS:

3.4 vs. 3.2, p: 0.4). The mean follow-up was 24 months and recur-

rence was observed in 4 patients and all patients were in group 1.

Conclusion: Poly-L-lactic-acid-polypropylene patch significantly

decreased the number of mesh fixation times and did not cause hernia

recurrence during follow-up.

P-1006

Prevention procedure for the development ofinguinal

hernia after prostatic surgery

Jorge Barreiro J, Garcia Bear I, Pire Abaitua G, Minguez

Ruiz G, Serra Lorenzo R, Gutierrez Corral N, Delgado

Sevillano R, Serrano Gonzalez S, Campos Alvarez CUniversity Hospital San Agustin

Background: It is well known that inguinal hernia after retro-pubic

prostatectomy is common adverse event. We have evaluated our

series of inguinal hernia after prostatectomy and assessed the effect of

simultaneous prevention procedure carried out at prostatectomy.

Object and method: From 2003 to 2016, 97 patients who were

carried out retro-pubic prostatectomy at single cancer center and

diagnosed as postoperative inguinal hernia were referred to our

ABSTRACTS

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http://dx.doi.org/10.1016/j.ijsu.2018.04.014

institution. At this cancer center dissection of peritoneum from vas

deference and transection of processus vaginalis was carried out as

prevention procedure for inguinal hernia from 2009. Incidence of

inguinal hernia and association of prevention procedure were com-

pared and the effect was evaluated.

Results: Break down of the treated hernia was lateral hernia: 97.

Medial hernia: 3. Patients were classified into two groups by the

prevention procedure (Group-pre without prevention and Group-post

with prevention). Incidence of inguinal hernia in the Group-pre was

(5.9% 64/781) and in the Group-post was 4.1% (53/737). By cumu-

lative observation onset of inguinal hernia among Group-pre was

6.1%: 1 year, 6.2%: 2 year, 3.5%: 3 year, 6.6%: 5 year, 6.3%:

6 year). Those among Group-post were (1.9%: 1 year, 2.3%: 2 year,

2.9%: 3 year, 3.4%: 4 year, 2.8%: 5 year) respectively. Incidence of

inguinal hernia in the Group-pre was statistically higher than that in

the Group-past. 3 year: p\ 0.01, 2 year, 4 year, 6 year: p\ 0.05,

4 year: p == 0.09 by Chi square) Mean interval of prostatectomy and

onset of hernia was 8 months in the Group-pre and 9 months in the

Group-post. The difference was not statistically different. (p = 0.75

Mann–Whitney test).

Discussion: Our result remonstrated that simple prevention procedure

could satisfactory reduce the incidence of inguinal hernia by 60%.

These results suggested possible role of processus vaginalis in

development of inguinal hernia.

P-1007

Incarcerated abdominal wall hernia: experience on 200

cases

Jorge Barreiro J, Garcia Bear I, Minguez Ruiz G, Pire

Abaitua G, Campos Alvarez C, Delgado Sevillano R,

Serrano Gonzalez S, Gutierrez Corral N, Serra Lorenzo RUniversity Hospital San Agustin

Objectives: Incarcerated and strangulated abdominal wall hernias are

life-threatening conditions requiring prompt surgical intervention,

irrespective of location. In addition, emergency hernia repair carries a

substantial morbidity and mortality risk. The aim of this study was to

share the experiences and outcomes of treatment of incarcerated

abdominal wall hernia in a large teaching hospital.

Methods: This is a retrospective analysis of electronic patient charts.

All patients who underwent surgery for incarcerated abdominal wall

hernias from January 2007. Until December 2015 were analyzed. Pre-

, peri- and postoperative parameters were analyzed. The validated

Clavien-Dindo classification (CDC) was used for post-operative

morbidity and mortality analyzed.

Results: A total of 200 patients were included for analysis. Male to

female ratio was 102.75. Median age was 63 years (range 21–90).

Mean BMI was 29.7 kg/m2. 51 patients were ASA-score 1; 72

patients ASA 2; 55 patients ASA 3 and two patients were ASA 4. The

majority of patients presented with an incarcerated umbilical hernia

(n = 72, 37.8%), followed by 45 patients with an inguinal hernia

(23.2%) and 39 patients with an incisional hernia (20.0%). In 92 cases

(51.1%), hernia contents were strangulated, and bowel resection was

performed in 29 patients (14%). Overall post-operative morbidity rate

was 45.2% (n = 71). 30% were CDCl–2 (n = 55), 11.6% CDC3–4.

30-day mortality in our series was 5.0% (9/180). ASA 3–4, age[ 90

and bowel resection were associated with significantly higher post-

operative complications (p\ 0.05). Mesh repair in incarcerated her-

nias was not associated with higher post-operative morbidity

compared to primary repair (p = 0.3).

Conclusion: Surgeons must be aware of the increased post-operative

risks in older patients, patients with significant comorbidities and after

hernia repair with bowel resection.

P-1008

Hernia repair in cirrhotic patients

Jorge Barreiro J, Garcia Bear I, Delgado Sevillano R,

Serrano Gonzalez S, Campos Alvarez C, Pire Abaitua G,

Sanchez Turrion V, Arias Pacheco R, Ramos Perez VUniversity Hospital San Agustin

Introduction: Cirrhosis is the end stage of severe liver damage

caused by hepatitis virus, alcohol and autoimmune hepatitis etc. We

sometimes encounter groin hernias and umbilical hernias in those

patients. I make a presentation about the general aspects of hernia

surgery to cirrhotic patients and our experiences.

Preoperative examinations: Cirrhotic patients often have some

typical symptoms which influence surgical procedures, such as

ascites, engorgement of the abdominal wall subcutaneous veins and

hypocoagulability. To identify ascites and subcutaneous varicose, CT

scan should be performed. Preoperative blood examinations for

hypocoagulability, such as platelet count, APTT, PT and HPT are also

necessary.

Anesthesia: Usually cirrhotic patients have hypocoagulability caused

by the decreased platelets and lowering of coagulation factors. Gen-

eral anesthesia is often preferred for hernia surgery to cirrhotic

patients. Epidural anesthesia or spinal anesthesia is not indicated.

Operative technique: Minimally invasive technique should be per-

formed to cirrhotic patients because of those symptoms caused by the

lowering of liver function. We mostly performed plug and patch

technique to minimize the area for dissection. Preperitoneal wide

dissection by TAPP, TEP and TIPP is not indicated, because it has a

high risk of retroperitoneal bleeding. Particularly, when retroperi-

toneal bleeding occurs following TAPP and TEP, it is difficult to

diagnose the amount of bleeding without CT scan. In all cases,

complete peritoneal closure is unavoidable.

Results: Between 2008 and 2017, we experienced 36 inguinal her-

nias, 5 umbilical hernias. Emergency operation was performed in 5

cases of inguinal hernias and 1 case of umbilical hernia due to

incarceration. Plug and patch was performed to elective inguinal and

umbilical cases. IP tract repair was performed to one emergency

inguinal case and simple closure to one umbilical emergency case

with intestinal resection. All cases recovered and discharged with

small complications after surgery.

Conclusions: Hernia surgery to cirrhotic patients has more risks than

usual. Considering all risk.

P-1009

Mesh suture for contaminated incisional hernia repair

Jorge Barreiro J, Garcia Bear I, Pire Abaitua G, Delgado

Sevillano R, Campos Alvarez C, Serrano Gonzalez S,

Minguez Ruiz G, Arias Pacheco R, Sanchez Turrion VUniversity Hospital San Agustin

Background: Suture closures of incisional hernias are recognized as

having high recurrence rates, while prosthetic planar meshes and

bioprosthetic meshes have their own drawbacks to use, especially in

non-sterile fields. In this study, we sought to evaluate the results of a

new technique that uses strips of mesh as sutures for closure of

contaminated incisional hernias.

Methods: 70 patients with contaminated hernias 5 cm wide or greater

by preoperative CT scan were closed with mesh sutures. Surgical site

occurrence, infections, and hernia recurrence were compared to

similar patient series reported in the literature.

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S51 Hernia (2019) 23 (Suppl 1):S50–S100

Results: Of 58 patients, 22 had clean-contaminated wounds, 20 had

contaminated wounds, and 16 were infected. 70% of the patients

underwent an anterior perforator sparing components release for

hernias that averaged 10.5 cm transversely (range 5–28 cm). SSO

occurred in 27% of patients while SSI was 19%. There were no

fistulas or delayed suture sinuses. With a mean follow-up of almost

12 months, 5 midline hernias recurred (6%). In these same patients,

three parastomal hernias repaired with mesh sutures failed out of 6,

attempted for a total failure rate of 15%.

Conclusion: Mesh sutured closure represents a simplified and effec-

tive surgical strategy for contaminated midline incisional hernia

repair.

P-1010

Early repair of ventral incisional hernia improves

quality of life after surgery for abdominal malignancy:

a prospective, case-controlled study

Jorge Barreiro J, Garcia Bear I, Pire Abaitua G, Aguado

Suarez N, Gutierrez Corral N, Ramos Perez V, Serra

Lorenzo R, Minguez Ruiz G, Arias Pacheco RUniversity Hospital San Agustin

Background: Recent work has shown that over 40% of patients

undergoing surgery for abdominal malignancy develop ventral inci-

sional hernias (VIH) after 2 years. We hypothesized that early repair

of a VIH for cancer survivors would improve long-term quality of life

(QOL).

Methods: All patients presented to our clinic with a history of surgery

for abdominal malignancy and a complaint of VII-I were prospec-

tively invited to enroll. QOL was assessed at baseline and 3, 6, 12, 18,

and 24-month follow-up using abdominal wall-specific (HerQLes)

and cancer-specific (FACT-G) instruments. At the study’s conclusion,

patients were divided into 2 groups—those that underwent VIH repair

during the study’s course (Repair Group) and those that did not

(Control Group). Categorical variables were analyzed using Pearson’s

Chi Square and continuous variables with Wilcoxon rank sum test.

Results: 100 patients were enrolled. Overall, 66 patients (55%)

underwent VIH repair, with 39 repairs (78%) occurring within

3 months of initial evaluation. 76 (79%) had complete 1-year follow-

up data, and 24 (36%) had 2-year data, with a mean follow-up

duration of 15.6 months. At baseline, both groups were similar with

respect to demographics, cancer stage, and HerQLes/FACT-G scores.

The Repair Group showed improvements over baseline HerQLes

scores at 3, 6, l2, and 18-month timepoints (median increasing

47–59), while the Control Group showed no improvement (median

increasing 49–54), p = 0.037. FACT-G scores in the Repair Group

similarly showed QOL improvement over baseline at the 3, 6, and l2-

month timepoints (median increasing 84–90), whereas the Control

Group did not (median increasing 82–86), p = 0.046.

Conclusions: Repair of VIH after surgery for abdominal malignancy

can improve abdominal wall-specific and cancer-specific QOL,

making post-resection abdominal wall reconstruction an important

aspect of cancer survivorship and suggesting a role for hernia pro-

phylaxis at the initial operation.

P-1011

Visceral obesity as a predictor of hernia recurrence

after abdominal wall reconstruction

Jorge Barreiro J, Garcia Bear I, Pire Abaitua G, Aguado

Suarez N, Gutierrez Corral N, Ramos Perez V, Arias

Pacheco R, Minguez Ruiz G, Serra Lorenzo RUniversity Hospital San Agustin

Introduction: High body mass index (BMI) increases the risk of

postoperative complications and recurrence after abdominal wall

reconstruction (AWR). However, BMI is an anthropometric measure

that does not provide specific information on mass and placement of

different tissues. We hypothesized that visceral fat volume (VFV),

measured on computed tomography (CT) scans, was a better predictor

than BMI for recurrence after AWR.

Method: Consecutive patients undergoing AWR at our institution

from 07/10/2010 to 05/12/2016 were included in this study. Data was

collected from a prospective database and all patients were sum-

moned for clinical follow-up. VFV was calculated from preoperative

CT scans using an automatic segmentation tool. The primary and

secondary outcomes were hernia recurrence and 30-day postoperative

surgical site occurrences (SSO), respectively.

Results: We included 200 patients undergoing AWR for a mean

hernia defect of 10.4 cm 9 16.5 cm (transverse x longitudinal). 60

patients (28%) developed recurrence during follow-up. VFV was

significantly associated with hernia recurrence (5.6 vs. 4.3 L,

P = 0.011, univariable analysis). After multivariable Cox-regression,

VFV remained significantly associated with hernia recurrence (HR

1.12 per 0.5 L increase of VFV, 95% CI 1.04–1.19, P = 0.018). In

contrast, BMI was not associate with hernia recurrence in the uni- or

multivariable analyses. (29%) developed a SSO. VFV was signifi-

cantly higher in the group of patients who developed SSO compared

to those who did not (mean 5.1 vs. 4.6 L, P = 0.011). A multivariable

logistic regression model showed that VFV was significantly associ-

ated with the development of SSO (OR 1.19 per 0.5 L increase of

VFV, 97% CI 1.14–1.27 P = 0.008).

Conclusion: VFV was significantly predictive of both hernia recur-

rence and SSOs after AWR. This study suggests VFV as a promising

risk assessment tool for patients undergoing AWR.

P-1012

Comparative analysis between laparoscopic vs open

inguinal hernia in a university hospital: Results

at 15 years


Ruiz G, Serra Lorenzo R, Gutierrez Corral N, Arias

Pacheco R, Aguado Suarez N, Delgado Sevillano RUniversity Hospital San Agustin

Introduction: Inguinal hernias are the most frequent, occupying

between 50 and 60% of all hernias in the abdominal wall. The

laparoscopic approach to inguinal hernia repair has been shown to be

beneficial in reducing postoperative pain and facilitating an earlier

return to normal activity.

Aims: To compare and analyze the results at 15 years of laparoscopic

vs open inguinal hernia repair. To classify the patients studied

according to the different variables: age, sex, type of surgery per-

formed. Compare recovery time to perform daily activities and return

to work activity.

Materials and methods: Retrospective, descriptive and observational

study. We included all patients (300 operated on inguinal hernioplasty

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Hernia (2019) 23 (Suppl 1):S50–S100 S52

between January 1, 2001 and December 31, 2016 Data were collected

by telephone survey, effective in 178 patients (60.3%) and Clinical

History analysis.

Conclusion: In our Hospital, both types of surgeries are indicated for

the repair of herniated defects of the groin. We did not find significant

differences in the recurrences and other complications, although in the

postoperative satisfaction of the patients, the shortening of time to

resume daily and work activity.

P-1013

Early experience with incisional fascial reinforcement

to prevent hernias: patient selection, techniques

and outcomes


Ruiz G, Serra Lorenzo R, Serrano Gonzalez S, Arias

Pacheco R, Campos Alvarez C, Sanchez Turrion VUniversity Hospital San Agustin

Introduction: Incisional hernias (IH) continue to increase morbidity,

cost and disability for patients. There may be an opportunity to

decrease rates of ll-I with incisional fascial reinforcement (IFR) at the

time of laparotomy. There have not been many studies detailing how

IFR fits into the hernia ecosystem-specifically, deciding what patients

may benefit from IFR and what techniques should be considered.

Herein, we will provide a dual-institution review of patient selection,

description of technique, and early outcomes after IFR.

Methods: A dual-institution retrospective chart review was per-

formed of prospectively collected data. Patient characteristics and

identifiable hernia risk factors were determined. Additionally, oper-

ative technique and early post-operative outcomes were observed.

Standard statistical tests were applied.

Results: 69 cases of IFR were analyzed, 39 of which were males. The

average age and BMI of patients was 58 and 29.5 respectively. The

most common procedures during IFR were colorectal 27, abdominal

aortic aneurysm (AAA) repair (18 and gynecologic 15). All patients

were counseled on mesh characteristics, surgical complications and

hernia morbidity. All cases used a biosynthetic mesh, with 22 placed

as an onlay. Average time for mesh insert, 29 min, was recorded for

14 patients. 6 of the cases had mesh fixed with fibrin glue. One patient

had a dehiscence, two had seromas, zero had SSI, and zero had lH

with 6-month average follow-up.

Discussion: Appropriate patient selection and risk counseling are

essential in ensuring that IFR is successful. The most feasible and

efficient techniques need to be implemented in order to decrease the

burden of IH. Early results using onlay placement of a biosynthetic

mesh in high-risk patients undergoing colorectal, AAA, and gyne-

cologic procedures seem promising. Further studies need to be

conducted in order to assess long-term efficacy in each of these

populations with this technique and type of mesh.

P-1014

Abdominal wall reconstruction: effect of BMI

on surgical outcomes

Jorge Barreiro J, Garcia Bear I, Pire Abaitua G, Arias

Pacheco R, Minguez Ruiz G, Aguado Suarez N, Ramos

Perez V, Serra Lorenzo R, de Paz Moran MUniversity Hospital San Agustin

Background: Incisional Hernias are the most common long term

complication following a laparotomy. There is a high recurrence rate

after primary herniorraphy without mesh, therefore mesh repair of any

hernia defect[ 2 cm is the standard of care due to a lower rate of

recurrence. Obesity is a risk factor in the development of incisional

hernia and a major risk factor for hernia complication. The aim of the

study was to evaluate the effect of obesity on surgical outcomes after

abdominal wall reconstruction.

Method: This was a single institution, retrospective study that

examined data between 2001 and 2016 of all patients that had

abdominal wall reconstruction (rectrorectus repair and component

separation repair). Patients were stratified into BMI[ 40 and

BMI\ 40. Records with missing relevant data and patients under-

going panniculectomy during the same inpatient stay were excluded.

Univariate analysis and multivariate logistic regression were used to

compare outcomes between the two groups.

Results: A total of 502 patients were identified after inclusion and

exclusion criteria were met. The BMI\ 40 group had 353 patients,

with a mean BMI of 31.6, and the BMI[ 40 group had 149 patients,

with a mean BMI of 45.8. Median length of follow-up was similar

between the two groups, 4.6 months for BMI\ 40 vs 4.2 months for

BMI[ 40. The BMI\ 40 group had a relatively higher rate of

recurrence at 5 vs 1% for the BMI[ 40 group (p = l). A multivari-

able analysis demonstrated BMI wasn’t a predictor of hernia

recurrence rate after surgical repair.

Conclusion: Results of the study show obesity did not significantly

contribute to recurrence of incisional hernia and post-operative

complications in patient who had undergone abdominal wall recon-

struction repair.

P-1016

Internal hernia through a congenital broad ligament

defect

Ierardi K, Beffa LKent Hospital

Introduction: Internal hernias are considered complicated hernias

and cause between 0.6 and 6% of all small bowel obstructions.

Rarely, internal hernias occur secondary to congenital mesenteric

defects. Our patient presented with an exceedingly uncommon cause

of internal hernia through a congenital defect in the broad ligament.

Case: A 62-year-old female presented with a 6-month history of

intermittent abdominal pain which acutely worsened on the day of

presentation. She described progressively smaller caliber stools over

the previous 3 months with minimal passage of flatus in the last day.

Her pain was rated at an 8/10 with some association with movement.

She had no previous medical or surgical history and was not taking

any medications. Vital signs showed she was afebrile with a blood

pressure of 180/80, heart rate of 103 bpm, and a respiratory rate of 20

breaths per minute. Clinical examination revealed a mildly tender, but

soft abdomen with high-pitched tinkling bowel sounds. Computed

tomography scan revealed a small bowel obstruction with a transition

point in the right adnexal region. She was admitted and failed to

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S53 Hernia (2019) 23 (Suppl 1):S50–S100

improve with conservative measures. Diagnostic laparoscopy

demonstrated herniation of small bowel through a defect in the broad

ligament medial to the right ovary. The bowel was reduced after

enlarging the internal hernia defect in the broad ligament. Due to

concern for future herniation the fallopian tube, ovary, and suspensory

ligament were removed, thus opening the entire right pelvic space.

Discussion: A defect in the broad ligament represents approximately

4–7% of all internal hernias. Surgical management is mandatory and

options include suture repair of the defect or salpingo-oophorectomy.

Salpingo-oophorectomy permanently eliminates the risk of recurrence

but should be reserved for post-menopausal patients. Surgeons may

also consider intraoperative prophylactic repair of broad ligament

defects when noticed incidentally to reduce future hernia risk.

P-1017

Reducing the incidence of postoperative urinary

retention in totally extraperitoneal laparoscopic

inguinal hernia repair: a prospective, randomized,

double-blind, placebo controlled trial

Shikhman A, Caparelli M, Allamaneni S, Hobler SJewish Hospital

Introduction: Post-operative urinary retention (PUR) occurs at a

higher frequency in laparoscopic vs open inguinal hernia repair

(1–22% vs 0.4–3%). Preoperative tamsulosin has been demonstrated

to decrease PUR, however, it has not been studied in laparoscopic

inguinal hernia repair (LIHR). In a previous retrospective review, we

have identified our PUR rate at 18.8% for LIHR. Our goal is to

determine the efficacy of preoperative tamsulosin on the incidence of

PUR.

Methods: A prospective, randomized, double-blind, placebo-con-

trolled trial was designed. All elective LIHR patients are randomized

to receive 0.4 mg dose of tamsulosin or placebo within 2 h preop-

eratively. Randomization and blinding is performed by the pharmacy.

Catheterization criteria include the inability to urinate within 6 h post-

operatively with confirmation by bladder ultrasound. To reach sta-

tistical significance approximately 350 patients will need to be

enrolled.

Results: Currently, we have enrolled 35 patients in the study. Urinary

retention has not yet been observed. We anticipate completion of data

collection by mid 2019.

Conclusions: Although our institutional rate of PUR is consistent

with current literature it remains a significant and frequent compli-

cation that demands improvement. We aim to study the efficacy of

preoperative tamsulosin in reducing the incidence of PUR. If suc-

cessful, this would be a strong contribution to our patients and the

surgical community by decreasing catheterization rates and unplan-

ned admissions as well as increasing patient satisfaction.

P-1018

Incidence of postoperative urinary retention in totally

extraperitoneal laparoscopic inguinal hernia repair:

single surgeon experience

Shikhman A, Caparelli M, Allamaneni S, Hobler SJewish Hospital

Introduction: Post-operative urinary retention (PUR) occurs at a

higher frequency in laparoscopic compared to open inguinal hernia

repair (1–22% vs 0.4–3%). Some previously described risk factors

include older age, history of BPH and general anesthesia. The aim of

this review is to identify our PUR rate for LIHR and determine the

associated risk factors.

Methods: Retrospective review of LIHR (170 patients Jan 2015–Jan

2017) by a single surgeon was performed and the rate of PUR was

defined by need for catheterization. Catheterization criteria included

inability to urinate within 6 h post-operatively with symptoms of

urinary retention and confirmation via bladder ultrasound.

Results: Postoperative urinary retention was observed in 18.8% (32/

170) of elective LIHR. PUR occurred in all males (92%) while

operation duration did not differ between groups (60 vs 69 min,

P = 0.08). All patients received general anesthesia. Bilateral repairs

were performed in 28% (OR 1.20, P = 0.68) of patients experiencing

retention. There was no difference in PUR between left and right

repairs (P = 0.28). Older age was a significant risk factor for PUR

(59.6 vs 66 years, P\ 0.05).

Conclusions: Our review indicates a PUR rate of 18.8% in LIHR.

Older age ([ 60 years) was the only significant risk factor con-

tributing to PUR. Although, our rate is in line with current literature

this remains a significantly common complication which deserves

attention in future studies.

P-1019

The grip concept: from bench to bedside in ventral

hernia repair

Kallinowski F, Gutjahr D, Harder F, Nessel RUniversity Hospital Heidelberg

Ventral hernia repair is burdened with high recurrence rates. A new

methodology resembling coughing actions was developed as a bench

test. It permits the assessment of the grip of a reconstruction. The

ability of ventral hernia repair to withstand dynamic impact strain

(DIS) is directly related to the grip of the reconstruction.

DIS impacts were delivered with a computer-controlled,

hydraulically driven tissue model (Kallinowski et al. Hernia

21:455–467, 2017 https://doi.org/10.1007/s10029-017-1583-1, 2017).

The GRIP concept was previously published (Kallinowski et al. Front.

Surg. 4:78. https://doi.org/10.3389/fsurg.2017.00078, 2018). A total

of 30 patients with incisional hernia were treated so far according to

the grip concept. Data were entered into the HERNIAMED registry

opening a new chapter called STRONGHOLD.

Within the first 3 months from September to December 2017, 15

patients (10 female, 5 male) were registered. Age ranged from 34 to

92 years (64.4 ? 12.2 years). Most patients were obese and had

known risk factors for the development of incisional hernia (10/15).

Patients were generally fit (93% ASA II and III). Elective repair was

performed in 14 cases. In one case, a bowel laceration was oversewn

intraoperatively without sequelae. Mesh size was on the average

10fold the defect size. In principle, the mesh was sutured in place (14/

15). The grip value was found to vary between 14 and 646

(mean ? SD: 105 ? 152) and tended to drop as hernia size increased.

Hospital stay was 6 days on the average (range 2–10 days). So far, no

recurrence occurred.

The grip calculation is a novel way to assess biomechanical sta-

bility in ventral hernia repair. In clinical practice, the grip tends to

drop as hernia sizes increase. Care should be taken to reach adequate

grip values even at larger hernia sizes.

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Hernia (2019) 23 (Suppl 1):S50–S100 S54

http://dx.doi.org/10.1007/s10029-017-1583-1

http://dx.doi.org/10.3389/fsurg.2017.00078

P-1020

Tissue elasticity markedly influences the grip of ventral

hernia repair

Nessel R, Gutjahr D, Harder F, Kallinowski FKlinikum am Gesundbrunnen SLK Kliniken Heilbronn GmbH

High recurrence rates are observed after ventral hernia repair. A

bench test to assess mechanical stability prior to surgery is highly

sought after. Dynamic intermittent strain (DIS) resembling coughing

actions permits the assessment of the stiction of a reconstruction. The

resulting measure is called grip. The ability of ventral hernia repair to

withstand DIS impacts is investigated to assess the influence of the

tissue elasticity on the grip values.

DIS impacts were delivered hydraulically with an aluminum

cylinder containing a plastic bag the flow of water being driven by

computer-controlled valves (Kallinowski et al. Hernia 21:455–467,

2017 https://doi.org/10.1007/s10029-017-1583-1, 2017). The GRIP

concept was previously used to develop safe fixation techniques

(Kallinowski et al. Front. Surg. 4:78.

https://doi.org/10.3389/fsurg.2017.00078, 2018). Since different tis-

sues exhibits various viscoelastic properties porcine bellies and beef

flank were compared using DIS impacts.

The viscoelastic properties of the tissues were assessed using

TissueAnalyzerTM. Beef flanks were found to have twice the elasticity

of porcine belly preparations taking double the stress as well. As a

results a prefabricated hernia defect of five diameters markedly

increased its size upon DIS straining in beef flanks up to 7.5 cm on

the average whereas porcine belly preparations varied ? 20% staying

almost constant on the average. Recalculation of grip values taking

the hernia size at the 10th DIS impact into account gave the same

result related to hernia size regardless of the tissue laxity.

The grip calculation is a novel way to assess biomechanical sta-

bility in ventral hernia repair. Higher grip values are necessary as

hernia sizes increase. This is more pronounced with increased tissue

laxity. Care should be taken to reach adequate grip values in lax

tissues.

P-1021

Outcomes of transversus abdominis release in emergent

incisional hernia repair

Alkhatib H, Tastaldi L, Krpata D, Petro C, Rosenblatt S,

Rosen M, Prabhu AThe Cleveland Clinic Foundation

Purpose: Elective repair of large incisional hernias using posterior

component separation with transversus abdominis release (TAR) has

acceptable wound morbidity and long-term recurrence rates. The

outcomes of using this reconstructive technique in an emergent set-

ting remains unknown. We aim to report 30-day outcomes of TAR in

non-elective settings.

Methods: All patients undergoing open TAR in non-elective settings

were identified within the Americas Hernia Society Quality Collab-

orative (AHSQC). Outcomes of interest were 30-day Surgical Site

Infections (SSIs), Surgical Site Occurrences (SSOs), SSOs requiring

procedural intervention (SSOPIs), medical complications, and

unplanned readmissions and reoperations.

Results: 61 patients met inclusion criteria. Mean BMI was

36.6 ± 8.8 kg/m2 and mean hernia width was 14.4 ± 7.1 cm. 42

(68.9%) were recurrent hernias and bowel obstruction was the most

frequent cause for emergent surgery (80.3%). Surgical field was

classified as clean in 68.9% of cases, with an 88.3% use of permanent

synthetic mesh and fascial closure achieved in 93.4%. There were 16

(26.2%) total wound events, 9 (14.8%) were SSIs. There were 9

(14.8%) SSOPIs, 7 of which were wound opening, 1 wound

debridement, and 1 percutaneous drainage. At least one wound or

medical complication was reported for 38% of the patients. There

were no mortalities.

Conclusion: Not surprisingly, TAR in an emergent setting is asso-

ciated with increased wound morbidity requiring procedural

interventions and reoperations compared to what has previously been

reported for elective cases. The long-term consequences of this

wound morbidity with regard to hernia recurrence are as of yet

unknown.

P-1022

Comparative study of desarada: tissue based technique

versus lichtenstein technique for primary inguinal

hernia repair

Jain MAIIMS, New Delhi

The presentation is a comparative and prospective study between

Desarda and tissue based technique versus Lichtenstein technique for

primary inguinal hernia repair. The study done was designed to

establish the clinical outcomes of hernia repair using the physiolog-

ically dynamic tension free inguinal herniorrhaphy using external

oblique aponeurosis, a non mesh tissue only repair, which is

acclaimed to be able to restore the normal physiology of the inguinal

canal as compared to the mesh based repairs. In this study there was

statistically significant difference between the physiologically

dynamic tension free inguinal herniorrhaphy using external oblique

aponeurosis and Lichtenstein method in regard to post operative pain

scores, mean hospital stay and return to daily activities. As far as peri

operative complications are concerned there was statistically signifi-

cant difference in frequency of seroma formation only.

The most evident indications for the use of the physiologically

dynamic tension free inguinal herniorrhaphy using external oblique

aponeurosis technique include:

1. Use in young patients.

2. In contaminated surgical fields.

3. In the presence of financial constraints or.

4. If a patient disagrees with the use of mesh.

The tissue only repair was shown to take a significantly shorter

operative time.

To conclude the tissue based herniorrhaphy showed better out-

comes in terms of,

1. VAS (pain).

2. ADLs.

3. Shorter operative time.

4. Reduced post operative complications of seroma formation.

Though the recurrence rate of physiologically dynamic tension

free inguinal herniorrhaphy using external oblique aponeurosis tech-

nique for hernia repair after a follow-up of 1.5 years is comparable to

that of Lichtenstein method which is considered a standard procedure

of management of inguinal hernia.

123

S55 Hernia (2019) 23 (Suppl 1):S50–S100

http://dx.doi.org/10.1007/s10029-017-1583-1

http://dx.doi.org/10.3389/fsurg.2017.00078

P-1023

Spontaneous lateral abdominal wall hernia containing

an incarcerated appendix

Caparelli M, Runyan B, Hobler SThe Jewish Hospital

Introduction: Lateral abdominal wall defects are a rare entity that

presents a unique challenge to surgeons. The lateral abdominal wall is

defined by the linea semilunaris medially, posterior paraspinal mus-

cles laterally, costal margin superiorly and iliac crest inferiorly. We

report a previously undescribed spontaneous lateral abdominal wall

hernia containing an incarcerated appendix that was repaired by an

open underlay technique.

Case: The patient is an 81-year-old female with a remote history of

hysterectomy that presented with a small, painful right lower quadrant

abdominal mass. She did not have a history of trauma, intra-ab-

dominal infection, incisional defects, smoking or obesity. CT scan

showed a 2 cm hernia defect in the right lower quadrant. The hernia

was 3 cm medial to the anterior superior iliac spine, lateral to the

rectus and superior to the inguinal ligament. The hernia protruded

through the transverse abdominis and internal oblique muscles and

contained a normal appendix. The patient underwent open surgical

repair with composite mesh placed in an underlay fashion.

Discussion: In this report we describe a new location for a lateral

abdominal wall hernia. Whereas Spigelian hernias protrude through

an area of weakness just lateral to the rectus sheath; the hernia that we

describe was located lateral to the semilunar line penetrating the

internal oblique and transversus abdominis muscles and contained a

hernia sac. The size and location of the defect was favorable for an

open approach, which we showed to be safe and effective.

P-1026

Comparison of intraperitoneal ventralex St Patch Vs

Onlay Mesh Repair in Small and Medium Primer

Umbilical Hernia

Agca B, Iscan YFatih Sultan Mehmet Training and Research Hospital

Aim: The high recurrence rates seen in non-mesh suture repairs

increase the demand for mesh suture repairs. Although the size of the

hernia plays an active role in the use of the mesh, the counter-view is

that the use of the mesh should be preferred regardless of the size of

the hernia. In our study, the clinical results of two different mesh

types applied under elective conditions to small-and medium-sized

umbilical hernia cases were examined.

Materials and methods: Between January 2015 and May 2018,

intraperitoneal Ventralex ST repair and onlayprolene mesh repair

were performed in 88 primary umbilical hernia cases. All patients

were over 18 years of age and had symptomatic and primary

umbilical hernia, the diameter of which was less than 4 cm. The

scoring of recurrence rates, short and long-term postoperative com-

plications and pain were calculated.

Results: The mean follow-up period was 23 months (with range

7–46 months) and no recurrence was observed in both groups. There

was no statistically significant difference between gender character-

istics, ASA scores, hernia defect diameters, hospital stay period and

return to work time. The duration of the surgery in Ventralex ST

group was 35.9 ± 4.1 min. (P\ 0.05). The BMI in Ventralex ST

group was 30.5 ± 3.5 kg/m2 (P\ 0.05).Analgesic intake in onlay

mesh group was 8.2 ± 1.9 (P\ 0.05). The VAS values of the 1st and

7th day of the onlay mesh repair group were statistically significantly

higher than the values of the Ventralex group. (P\ 0.05). The rates of

early and late postoperative complications such as seroma, hematoma,

wound infection, and recurrence were similar between the procedures.

Discussion: We think that the Ventralex ST mesh performed with

open surgical technique under elective conditions for primitive

umbilical hernias can be safely used because of its quick applicability

and low rates of complication and recurrence.

P-1029

A hierarchical postgraduate year competency based

model for robotic surgery education

Lewis J, Cervone A, Brandt JNorthwell, Peconic Bay Medical Center

Surgical resident education is an evolving paradigm encompassing

open operative technique and rapidly expanding minimally invasive

operations with the incorporation of robotic technology. Our goal is to

demonstrate a hierarchical education model that provides a step-wise,

competency-based learning process ultimately resulting in creden-

tialing in robotic surgery using the Da Vinci Surgical System during

the course of surgical residency. The competency-based model would

parallel The General Surgery Milestone Project� set forth by the

Accreditation Council for Graduate Medical Education.

The model’s benchmarks encompass the following categories:

Port Placement, Patient Cart Setup, Docking and Undocking, Instru-

ment Insertion and Exchange, Surgeon Console Settings, Camera

Control, Clutching, EndoWrist� Instrument Manipulation, 3rd Arm

Control, Range of Motion, Retraction, Dissection, Suturing, Applying

Energy, Troubleshooting and Communication. The resident would

also review recorded operations performed by a senior robotic sur-

geon. Additionally, the resident’s operative video will provide

constructive critiques for operative technique, ergonomics, and safety

metrics.

The DaVinci Residency and Fellow Training Program would be

the foundation for a curriculum based on a post-graduate year that

would be easily adoptable by training programs with extemporaneous

efforts. The model provides a structured solution for robotic education

while providing critical constructive feedback through senior resi-

dents and attending surgeons. Competent senior residents would

provide a social structure to mandate surgical competency of junior

residents in robotic surgery. As surgical resident education progresses

into data and performance-driven metrics so should a structured

credentialing process.

P-1030

Laparoscopic extraperitoneal endocopic staple based

sublay operation (LEESS) with mesh: interims analysis

of an initial patient cohort

Hashim D, Meyer F, Albayrak NSt. Anna Hospital Herne

Background: Patients with symptomatic midline abdominal hernia

(umbilical, infraumblical, port-a-cath, &/or epigastric hernias) and

concomitant rectus abdominis diastasis represent a growing clinical

problem. The optimal management of this complex hernia situation is

the subject of debate in the literature. This paper reports on the early

results of an innovative surgical technique aimed at managing this

hernia situation.AIM: To analyze early postop. outcome characterized

by morbidity (in particular, by intraop., specific and general com-

plication rate) and mortality based on a unicenter observational study

123

Hernia (2019) 23 (Suppl 1):S50–S100 S56

to reflect daily surgical practice in hernia surgery using a novel sur-

gical approach such as LEESS.

Methods: LEESS with mesh a is a surgical technique recently known

in the literature for its good outcome for midline hernia repair via

transperitoneal route (Brazilian Technique) & Endoscopic Compo-

nent Separation Techniques. The early postop. outcome results for the

first 50 patients are presented here in this systematic clinical unicenter

observational study on quality assurance.

Results: Two patients (4%) developed postoperative complications

requiring redo surgery. These were two cases of internal herniation

through a defect in the posterior rectus sheath, the herniated intestine

was reduced and the defect was sutured laparoscopically. All other

complications were successively managed with conservative treat-

ment. After 11 months, 4 out of 50 (8%) patients reported occasional

pain, including pain at rest in one patient. 5 out of 50 (10%) devel-

oped a symptomatic subfascial seroma.

Conclusion: The LEESS technique with mesh augmentation is an

innovative, minimally invasive surgical procedure for treatment of

patients with a complex abdominal wall hernia comprising symp-

tomatic umbilical, port-a-cath, and/or epigastric hernias with

concomitant rectus abdominis diastasis.

P-1031

Simultaneous umbilical hernia repair is a necessary

part of strategic planning for laparoscopic

cholecystectomy

Morfesis FOwen Drive Surgical Clinic

Umbilical defects (primary, post-partum and incisional) can cause

technical problems in laparoscopic cholecystectomy (LC) operations

(1). They interfere with trocar placement and can contribute to inci-

sional hernia postop. Additional contributing factors include prior

incisions (C-sections, where prior umbilical defect may not have been

effectively closed and tubals), prior abdominoplasty which can affect

blood supply and healing of trocar sites and need for mini-lap to

remove enlarged gall bladders. A cohort of 100 LC over a 5 year

period was retrospectively reviewed: 100 cases with a minimum of 6

month followup:27 men and 73 women, average age approximately

50 years. Risk factors for a variety of hernia defects (above) were

reviewed and total patients at risk from factors estimated at about

60% of female patients (prior C-section, tubals, minilap, abdomino-

plasty, primary hernias and prior surgery in abdomen)and 10% of

male patients (related to 5% estimate of underlying hernias and 5%

incidence of minilap. extraction of gall bladder): 27 of these 100

patients had concomitant defects repaired; the defect was used as a

primary trocar site whenever possible and then repaired with

absorbable suture if incidental, permanent suture if larger and biologic

re-inforced if defect greater than 2.5 cm in diameter. Detection, use

and repair of these defects was part of strategic planning of surgery;

the risk otherwise could contribute to incisional hernia risk postop.

There were no infections (other than expected SSI rate treated only

with antibiotics orally), complications or recurrences. (1) LC

accompanied by umbilical hernia repair; E. Kamer et al.; JPGM 2007,

vol 53, p 176–180.

P-1032

Inguinal hernia repair with a new fixation free 3d

multilamellar preperitoneal implant

Malik D, Dhakad DEternal Hospital

Objective: Prosthetic reinforcement is the gold standard in inguinal

hernia repair. Almost 20–30% patients complain of postoperative pain

due to irritation and inflammation caused by the mesh and methods of

fixation and about 4–10% of these, feel severe chronic postoperative

pain. So a single arm study was conducted for the assessment of

postoperative pain after inguinal hernia repair with a new 3D, mul-

tilamellar self-fixating Proflor mesh.

Methods: From Oct 2012 to July 2018, 265 patients of Inguinal

hernia were repaired with Proflor mesh (a new frixation free 3D

multilamellar preperitoneal implant- Insightra) where no suture fixa-

tion was done. All patients were assessed on visual analog scale

(VAS) at 7 days, 3 months, 6 months and 1 year and examined for

perioperative/postoperative complications.

Results: According to VAS, pain was reported in a range from 1 to 3

during the first week. No perioperative complications occurred. 22

postoperative complications were reported. 10 seromas,2 ecchymosis,

9 hypoaesthesia, 1 postoperative pain from 7th postoperative day

onwards which was initially intolerable but reduced in intensity after

2 months and was minimal at the end of 6 months. No recurrence was

found.

Conclusions: Postoperative complication rates were comparable to

the world literature. The use of this new mesh could be an alternative

method to reduce chronic postoperative pain after inguinal hernia

repair. Although further studies with long term results are still needed

to establish it as a gold standard.

P-1034

Learning curve for unilateral endoscopic totally

extraperitoneal (TEP) inguinal hernioplasty

in a teaching hospital our country

Agca B, Iscan Y, Memisoglu KUniversity of Health Sciences, Fatih Sultan Mehmet Training

and Research Hospital, General Surgery Department

Purpose: More than a hundred different techniques for repair of

inguinal hernia and femoral hernia has been described. In the guide

published in 2018, only open mesh technique and laparo-endoscopic

mesh techniques are generally approved. We sought to estimate the

learning curve for laparoscopic TEP repair in a teaching hospital our

country.

Methods: Patients with a primary unilateral inguinal hernia who

underwent laparoscopic TEP repair between the dates of May 2013

and May 2018 were included in the study. The patients were divided

into seven groups. The first four groups consisted of 20 patients and

the other three groups consisted of 100 patients per group.

Results: 349 of the 380 patients were male and 31 were female and

the mean age was 52 ± 14.2 (SD) years. The mean duration of

operation was 46 ± 25.9 (SD) minutes. There was a statistically

significant difference between the groups in terms of the duration of

the operation (p\ 0.05). The duration of the operation plateaued

as\ 1 h after 60 surgeries. A total of 7 patients were converted to

open surgery. Seroma and hematoma in 3 patients and hernia recur-

rence in 4 patients were detected.

Conclusions: It has been concluded that a surgeon performing a

certain number of inguinal hernia operation in her/his surgical career

can complete the learning curve for TEP repair after 60 operations

123

S57 Hernia (2019) 23 (Suppl 1):S50–S100

when appropriate technical conditions are provided, and that subse-

quent surgery can be performed in an optimal time with low

complication and recurrence rates.

Keywords: Laparoendoscopic repair, TEP, learning curve, duration

of surgery.

P-1035

Finding the optimal mesh for hernia patients- is

comprehensive mesh labelling adequate?

Karatassas A, Hensman C, Pantinniot P, Reid J, Leopardi

L, Nabeel I, Maddern G, Hewett P, Anthony AUniversity of Adelaide, Discipline of Surgery, The Queen Elizabeth

Hospital

Blatnik and others advocate comprehensive mesh labelling (size,

composition, pore size, weight, barrier protection and biomechanical

properties) providing a quick overview of key properties, optimising

mesh selection. This approach, supported by the AHS, presumes that

comprehensive labelling will allow surgeons to extrapolate regarding

the tissue response to the mesh and hence eventual patient outcome.

Although helpful, this is a crude method for determining patient’s

tissue response to mesh. A better, more scientific approach involves

developing a mesh tissue integration (MTI) index based on an animal

model. Currently, there is no universal model that is used to compare

meshes. We require one model, with standardized methods of inter-

pretation to allow comparison of meshes. We propose a porcine

model, placing mesh in subrectus and intraperitoneal positions (with

barrier protection). Analysis will be performed using specific

macroscopic and microscopic parameters based on International

Standards (ISO 10993-6) to obtain a grade from 0 to 5 on the fol-

lowing components;

• MTI Index (rate of tissue integration over 3 months).

• Fibrotic sub-index (degree of fibrosis).

• Adhesion sub-index (degree of adhesions for an intraperitoneally

placed mesh).

• Mesh degradation sub-index (to measure rate of degradation or

resorption of the mesh in vivo after 2 years).

An optimal mesh with ratings of five in each category will have

rapid MTI, minimal fibrosis or adhesions and no resorption. Based on

these four components surgeons may select mesh which is appropriate

for their patient.

It is simplistic to believe that indices based on animal studies

translate into predictable patient outcomes considering the diversity

and complexity of patients (as multiple medical comorbidities influ-

ence the tissue response to the mesh). To appreciate the significance

of the MTI index, a longitudinal database that records mesh indices

and patient characteristics against outcomes is pivotal in progressing

hernia management towards a truly holistic and tailored approach.

P-1036

Complex diaphragmatic and ventral hernia repair

after damage control thoracoabdominal surgery

Siegal S, Orenstein SOregon Health and Science University

We present a challenging diaphragm and ventral abdominal closure

after damage control thoracoabdominal surgery. A 40-year-old female

with T3N2 esophageal adenocarcinoma underwent laparoscopic

esophagectomy complicated by aortic laceration and massive blood

loss requiring open conversion with thoracoabdominal incision for

hemorrhage control. Damage control necessitated temporary closure

with negative pressure therapy. Subsequent esophagectomy was

completed with temporary chest and abdominal closure. During

intraoperative examination on postoperative day 8, the diaphragmatic

defect was noted to be under significant tension. A bridged repair was

performed, suturing to the edges of the left hemidiaphragm and

central tendon of the diaphragm. Biologic mesh was utilized due to

concern for infection from prolonged open abdomen. On postopera-

tive day 10, she underwent complex abdominal closure of a 17x30 cm

defect with bridged vicryl mesh. This was covered with bilateral

lipocutaneous advancement flaps over a 20x25 cm area. Undue ten-

sion was noted in the subxiphoid location, thus a negative pressure

wound dressing was applied to this area. After a prolonged intensive

care unit course, the patient was transferred to the ward on postop-

erative day 31, receiving enteral nutrition through her jejunostomy

tube. She was safely discharged home on postoperative day 39.

2 weeks later she was seen for follow up. Her wound was mostly a

bed of healthy granulation tissue, though there was some superficial

tissue necrosis at the inferior margin requiring bedside debridement

and punctate areas of exposed mesh along the thoracotomy aspect of

the incision. She was otherwise tolerating her feeds, taking recre-

ational oral intake, and having improved energy and ambulation.

Ongoing wound care efforts continue at this time, and the patient will

be evaluated for a future abdominal wall reconstruction following

completion of chemotherapy and preoperative optimization. This case

highlights unique surgical technique and decision making in a com-

plex hernia closure after damage control thoracoabdominal incision.

P-1039

Assessing risk in patients with liver failure: do risk

calculators over estimate a patient’s risk of mortality

following hernia repair?

Jackson J, Helm M, Turner B, Goldblatt MMedical College of Wisconsin

Background: Abdominal hernia repairs are common procedures;

however, patients with cirrhosis are known to be at considerable risk

for hernia repair. Several morbidity and mortality risk assessment

calculators for patients with liver disease have been developed to

attempt to add objectivity to the decision of whether these surgeries

should be performed. We sought out to determine if these risk cal-

culators accurately determined the mortality rate for hernia repairs.

Methods: The American College of Surgeons National Surgery

Quality Improvement Program datasets from 2013–2016 were queried

for patients who underwent an abdominal hernia repair. Patients were

included if they had pre-operative ascites and an American Society of

Anesthesiologists classification of III/IV. Mayo Clinic’s ‘‘Post-

Operative Mortality Risk in Patients with Cirrhosis’’ risk calculator,

Model for End-Stage Liver Disease (MELD) calculator, and a sur-

gical 5-item modified frailty index were assessed to determine

whether they accurately predict morbidity and mortality following

abdominal hernia repair. All predicted mortalities were compared to

the actual incidence of mortality. A high c-statistic indicates excellent

predictive performance of a risk calculator.

Results: In total, 560 patients met inclusion criteria. All risk calcu-

lators overestimated the risk of mortality. ‘‘Post-Operative Mortality

Risk in Patients with Cirrhosis’’ yielded an AUC = 0.76 and

p-value\ 0.0001. MELD score predicted mortality yielded an

AUC = 0.73 and p-value\ 0.0001. The modified 5-item frailty index

yielded an AUC = 0.54 and p-value of 0.46.

Conclusions: None of the three risk assessment calculators that were

examined are good mortality predictors following hernia repair in

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Hernia (2019) 23 (Suppl 1):S50–S100 S58

patients with cirrhosis and ascites. All of the mortality predictors

over-estimate the true 30-day operative mortality. The ‘‘Post-opera-

tive Mortality Risk in Patients with Cirrhosis’’ was the best predictor

of mortality.

P-1040

Repair of umbilical hernia resolves concomitant ascites;

umbilical hernia acting as a ‘‘Pump’’ for ascites

Morfesis FF Morfesis

48 year old cirrhotic patient (alcoholism) had clinical evidence of

transudative ascites (symptomatic) with rapid expansion of umbilical

hernia containing fluid. The hernia was successfully repaired with

resection of large portion incarcerated round ligament using suture

(hernia diameter about 2.5 cm.). 1 year follow up confirms resolution

of clinical evidence of ascites with resection of round ligament

incarceration and hernia repair, in absence of other clinical maneu-

vers. Pathology of round ligament otherwise unremarkable without

gross evidence of large veins. Clinical result could be consistent with

round ligament acting as a ‘‘pump’’ shifting transudate into lower

pressure umbilical hernia area outside of abdomen causing accumu-

lation of fluid and rapid expansion. The pressure differential between

intra-abdominal venous pressure of, for example, 18 mm Hg and

outside pressure (theoretically only pressure of skin) of hernia could

explain this observation. Additional data and observation and anec-

dotal findings could be useful to interpret and confirm validity of this

observation. Normal transudative ascites is thought to only accumu-

late above intra-abdominal venous pressure of 20 mm. HG but a

marginally lower pressure could account for accumulation in presence

of incarcerated ‘‘sump’’ for fluid and resolution when ‘‘sump’’ is

resolved. As long as pressure of resistance to stretching of skin was

less than this venous pressure, this would lead to accumulation of

fluid and resultant expansion of hernia and observation noted.

P-1046

False positive imaging results diagnosing occult

recurrent inguinal hernias

Ongos K, Albin M, Albin DHernia Center of Southern California, Inc

Inguinal hernia repairs are one of the most commonly performed

procedures in general surgery. Every year it has been estimated that

about 20 million inguinal hernia repairs are performed around the

world. After hernia surgery, it is common for hernia specialists to see

patients that experience discomfort or pain. Chronic inguinal pain has

been experienced by 18% of patients after undergoing open inguinal

hernia repair, while 6% of patients experienced chronic pain after

laparoscopic groin hernia repair. The patients with persistent pain fall

into two categories: recurrent hernia or inguinodynia, resulting from a

neuropathy of some type. In the absence of hernia reoccurrence on

physical examination, these patients will usually get either a diag-

nostic CT scan, an ultrasound, or an MRI. In this study, we focused on

the operative findings of patients who have had prior hernia surgery

with an imaging study that was positive for an occult recurrent

inguinal hernia. An occult hernia was defined as an imaging detected

recurrence that was not present on examination. Patients experiencing

chronic pain in the absence of a occult recurrent hernia were excluded

from the study. Preliminary findings showed a false positive rate of

50%. In these cases, the most common operative findings were a cord

lipoma or scar tissue. Often these patients complain of pain out of

proportion to what was seen operatively and would be expected.

Clinical judgment is imperative in determining the need for surgery in

these patients. Our objective is to treat the patient and not the radi-

ological findings.

P-1047

Improved anchoring mechanism for hernia repair mesh

Levinson H, Ibrahim M, Everitt J, Green J, Ruppert DDuke University Medical Center

Ventral hernia recurrence is the leading complication (* 30%

10-year recurrence rate) following hernia repair and it is caused by

anchor point failure at the mesh, suture, tissue interface. To overcome

this problem, we developed a hernia mesh (T-line mesh) with inte-

grated anchoring mesh extensions, akin to roots of a tree, that are 15

times the width of #0 suture and replaces the need for suture fixation.

Mesh extensions enhance high-tensile load distribution; significantly

reducing tissue stress and anchor point failure. Pre-clinical proof of

concept data is presented herein. The T-line mesh was knitted from

polypropylene (a heavy-weight, macroporous, mesh construction)

with equivalent physical characteristics (e.g. thickness, pore area, and

areal density) to a predicate mesh. The T-line mesh outperformed the

predicate mesh in all benchtop mechanical tests (i.e. suture retention

strength, ball burst, tongue tear resistance, and tensile strength and

strain). The T-line mesh and predicate mesh were implanted in a

swine ventral hernia model (n = 4/group) for 1, 30 and 90 days. Upon

analysis, there were no abnormal gross findings from either mesh.

Inflammation, bio-incorporation and fibrosis were statistically similar

between the T-line mesh and predicate mesh. The predicate mesh was

noted to contract more than the T-line mesh. The T-line mesh

anchoring strength (134.5 ± 54.5 N) was * 275% greater than the

predicate mesh anchoring strength (49.0 ± 13.4 N); exceeding

physiologic thresholds. The T-line mesh has supra-physiologic

anchoring strength, overcomes the most common mechanical failure

modes of currently used commercial meshes, and meets early safety

standards for implantation in humans. The data presented in this

abstract are the basis for ongoing commercial development of a novel

T-line mesh for durable hernia repair and hernia prevention.

P-1048

Laparoscopic hiatal hernia repair in association

with Nissen–Rossetti fundoplication: outcomes

and experience

Santivanez Palomino J, Nassar R, Ricaurte A, Hernandez J,

Escobar R, Giron FHospital Universitario Santa Fe de Bogota

Introduction: Hiatal hernias are common disorders characterized by

the protrusion of any abdominal structure other than the esophagus

into the thoracic cavity through a widening of the diaphragmatic

hiatus. In patients with confirmed gastro esophageal reflux, antireflux

surgery is an option for the management of their condition. Some-

times the hernia is not the indication for the procedure but when

repaired, according to the type of hernia, a fundoplication to address

reflux disease may be mandatory. We present our experience with

laparoscopic hiatal hernia repair in association with an anti-reflux

technique.

Methods: Retrospective case series. All fundoplication laparoscopic

cases performed by one surgeon where recorded between 2013 and

123

S59 Hernia (2019) 23 (Suppl 1):S50–S100

2017. Data recorded included demographic data, hernia defect size,

mesh time, and complications, and two- year follow up. A descriptive

analysis of the available demographic variables and risk factors was

carried out, as well as postoperative outcomes and follow-up. The

data are presented according to the nature of the variables.

Results: 44 patients were included. Body mass index was 28.5 kg/m2

(range 19–45 kg/m2), among which 11 patients were obese. From the

44 patients, 40 (90.9%) underwent primary sutured crural repair and 5

(11.4%) had mesh reinforcement. Laparoscopic Nissen-Rossetti fun-

doplication was performed in 34 patients (77.2%), and modified Hill

in 6 patients (13.6%). According to the hiatal hernia classification: 21

patients (47.7%) had type 1, 7 patients (15.9%) type 2 hernia, 13

patients (29.5%) type 3 and 3 patients (6.8%) had type 4. The com-

plication rate was less than 1% and there was no conversion to open

surgery. In the two-year follow up 4 patients (9%) had reflux, and 2

(2.5%) reported hernia reproduction.

Conclusions: General primary crural repair in association with

modified posterior gastropexy (Nissen-Rossetti fundoplication) pro-

vides favorable protection from gastroesophageal and pharyngeal

reflux and can be properly used in the treatment of GERD.

P-1049

Laparoscopy is the gold standard in the treatment

of inguinal hernias in young workers, comparative

study about 800 cases

Zatir S, Medjamea A, Haridi A, Mejahdi S, Nassim O,

Arbouz M, Meliani B, Selmani ZMilitary Hospital University of Oran

We adopted the treatment of inguinal hernias by laparoscopy see the

postoperative benefits of this surgical approach. We operated 400

patients for inguinal hernias of age a period of 04 years, the age of our

patients varies between 20 and 45 years, all our patients are profes-

sional soldiers, 48% right hernia, inguinal hernia 35% left, 13%

inguinal bilateral hernias, 4% recurrent hernias.so we compared our

results with 400 patients operated for inguinal hernia by lichtestein

procedures.

P-1051

Improved hernia measurement: initial outcomes

of a novel retractable laparoscopic measuring device

Soriano I, Wernsing DPennsylvania Hospital

Aims: To demonstrate the benefits of using a novel retractable la-

paroscopic measurement device (RLMD) to determine the size of a

hernia compared to other current measurement methods.

Backgorund: Current methods of hernia measurement are either

inaccurate, cumbersome, or both. A novel RLMD allows the surgeon

to quickly and accurately measure the internal aspects of the hernia

for proper mesh sizing.

Methods: Eight surgeons from multiple institutions were asked to

measure 3 defects on each of two laparoscopic hernia repair simu-

lators using different methods of measurement. They were first asked

to estimate the defect size by eye, then by using the grasper, and then

by using the RLMD. After measuring the 3 defects on the first sim-

ulator, they were then asked to move on to the second simulator to

measure replicated defects that were identical to the first simulator.

Results: On hernias[ 7.5 cm, the average absolute error for each

method was 3.8 cm (r = 2.6 cm) when estimating by eye, 1.7 cm

(r = 2.3) when using graspers, and 0.6 cm (r = 0.5 cm) when using

the RLMD. The difference in measurement when measuring the same

sized defects in each simulator also varied with each method. When

estimating by eye the difference was 2.6 cm (r = 2.5), the grasper

method was 1.5 cm (r = 2.4), and RLMD was 0.7 cm (r = 0.6 cm).

Conclusion: The RLMD was more accurate and consistent than the

other two laparoscopic measurement methods.

P-1054

Robotic transversus abdominis release: one year

outcomes in a community setting

Manieri C, Rhemtulla I, Santoro PChristiana Care Health System

Background: The morbidity of complex ventral hernia repair using

open component separation techniques has been well described. Our

aim is to investigate and discuss short term outcomes after complex

abdominal wall reconstruction utilizing a robotic transversus abdo-

minis release (TAR) in a community setting.

Methods: A retrospective review of a prospectively maintained

database of abdominal wall reconstruction cases performed by a

single surgeon was conducted at an independent academic community

hospital system from May 2017 to June 2018. Inclusion criteria

included a TAR and robotic approach. Patients underwent a stan-

dardized technique of abdominal wall reconstruction using robotic

assistance, with no open conversions. Our primary outcome for this

review was hospital length of stay. Secondary analysis included

surgical site infections, complications, readmissions, and operative

time.

Results: 16 patients were identified within the study period. The

average patient age was 54 (36–74) and BMI was 34 (26–49). The

average length of stay was 2.1 hospital days (1.1–3.4). There was 1

surgical site event consistent with a non-infected seroma. There was 1

readmission for pneumonia and pericarditis over a 30 day period.

There was no hernia recurrence within the study period and no patient

was lost to follow-up. The average time on the robotic console was

228 min (170–319) and the average defect measured 96 cm2

(25–217).

Conclusion: Robotic-assisted abdominal wall reconstruction is a

viable option in the repair of complex ventral hernias. It appears to

have low morbidity, short length of stay, and can be safely imple-

mented in a community hospital setting. These results add to the very

limited data available regarding robotic abdominal wall reconstruc-

tion. More investigation is needed to validate these findings as well as

to determine long term hernia recurrence rates.

P-1055

A single centre study of the frequency of complications

post open primary ventral hernia mesh repair: on lay

versus in lay techniques

Dhadlie S, Vujcich E, Ratnayake SCaboolture Hospital

Introduction: Open mesh ventral hernia repair is a common proce-

dure performed by general surgeons. Recent meta-analysis comparing

in lay to on lay mesh repairs demonstrated a lower frequency of

surgical site infection with in lay repairs. There was no difference in

the rate of recurrence or seroma formation.1 Ventral hernias and the

complications from repair can significantly affect an individual’s

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Hernia (2019) 23 (Suppl 1):S50–S100 S60

quality of life and have health care implications in relation to pro-

longed admissions and readmissions. 2, 3.

Design: Retrospective study of patients who had a primary ventral

hernia mesh repairs that were readmitted within 30 days of the pro-

cedure between 1st May 2015 to and inclusive of 31st May 2018.

Patients: 312 patients had primary ventral hernia repairs (including

umbilical hernia mesh repairs). 71 were readmitted within 30 days of

their procedure, 29 of which had complications related to the pro-

cedure. 41% patients were male.

Results: 80% of readmission had an on lay repair. The mean length of

readmission was 2 days. The mean time to readmission was 16 days

(range 1–30 days).

The mean age of patients was 51 (range 31–84 years). 30% of patients

had type 2 diabetes, vascular disease or obesity. Complications were

attributed to haematomas (17%), infected seromas (73%) and wound

infection (10%). There was a return to theatre in 34% cases.

Polypropylene (prolene) mesh was used in 60% of cases.

Conclusion: Infected seromas as complication of on lay mesh repair

was the most frequent readmission. There are several factors that are

known to affect the risk of developing incisional hernia and contribute

to poor outcomes post hernia repair such as age, obesity, infection,

diabetes and smoking.3 Only one-third of patients had these comor-

bidities which suggest that the technique of repair.

P-1056

Long-term results of laparoscopic totally extra-

peritoneal groin hernia repair with self-gripping

polyester mesh

Stavert B, Chan D, Ozmen J, Loi KSt George Public Hospital, Sydney, Australia

Background: Laparoscopic groin hernia repair is an increasingly

common procedure, with benefits of reduced post-operative pain and

infection. Postoperative chronic pain remains an ongoing concern in

about 10% of patients. Parietex ProGrip (Covidien, Dublin, Ireland), a

polyester self-gripping mesh, has a theoretical benefit of avoiding

tacks for mesh-fixation. This case series reflects our long-term

experience of this technique. Methods: We conducted a retrospective

case series with two surgeons from November 2011 to December

2017. Patients were identified through operative Medicare Benefits

Schedule item number search (laparoscopic groin hernia repair,

30,609). Clinical documentation was reviewed, with length of stay,

mesh infection, chronic pain, recurrence and reoperation as primary

data points. Results: A total of 514 patients underwent 780 laparo-

scopic inguinal hernia repairs with self-gripping polyester mesh

during this period. There were 53 female (10.3%) and 461 male

patients (89.7%). Unilateral hernia repair was performed in 248

patients (48.2%).

P-1058

Postoperative abdominal wall bulging of laparoscopic

ventral hernia repairs

Tang J, Zhu L, Li SHuadong Hospital Affiliated to Fudan University

Background: Laparoscopic ventral hernia repairs (LVHR) is one of

most popular operations in general surgery. Postoperative abdominal

wall bulging which was rarely mentioned in the past decades is one of

the common postoperative complications of LVHR. This study aims

at systematic reviewing abdominal wall bulging following LVHR.

Methods: A computer-aided search of the PubMed and Embase

databases was conducted to find relevant English-language publica-

tions on the postoperative abdominal wall bulging of laparoscopic

ventral hernia repairs. The following search terms were used: [la-

paroscopic surgery AND (ventral hernia OR incisional hernia) AND

postoperative complication AND (bulging OR protrusion OR even-

tration OR pseudoreccurence)]. No beginning date limit was used.

The search was updated until 31 July 2018. Review articles, meta-

analyses, abstracts, editorials or letters, case reports, tutorials and

guidelines for management articles were excluded. Full-text articles

were then reviewed to definitively determine if the study was eligible

for inclusion.

Results: A total of 11 studies were included for evaluation. The

incidence of LVHR postoperative abdominal wall bulging was

1.3–21.5%. Postoperative abdominal wall bulging may be related to

the area of abdominal wall defect, defect closure in operation, and the

type of implant patch. A patient could be diagnosed as post-LVHR

abdominal wall bulging if he/she meets the criteria in medical history,

clinical features and imaging examination. As preventions, surgeons

should pay attention to recognition and full exposure of fascia defect

edge, returning hernia content, fascia defect closure and patch overlap

and fixation in primary LVHR. When a re-operation is employed,

surgeon could fix a larger mesh tightly over the previous mesh.

Conclusions: Abdominal wall bulging after laparoscopic ventral

hernia repair is not a rare complication and should be diagnosed

carefully. A second surgery is needed when patients dissatisfied with

abdominal wall appearance or dysfunction. Prevention is always

better than treatment.

P-1059

Association of Wilms Tumor 1 gene polymorphism

with inguinal hernia in Chinese Han population

Zhu L, Li S, Tang J, Wang NHuadong Hospital Affiliated to Fudan University

Purpose: Inguinal hernia repair is one of the most commonly per-

formed operations in the world, yet little is known about the genetic

mechanisms that predispose individuals to develop inguinal hernias.

A genome-wide association study identified Wilms Tumor 1 gene

(WT1) as one of novel susceptibility loci underlying inguinal hernia

and 8 single-nucleotide polymorphisms (SNPs) of WT1 were reported

significant in western world. However, this result had not been veri-

fied in Chinese population. Our study aims at confirming the

association of WT1 polymorphism with inguinal hernia in Chinese

Han population.

Methods: 91 participants with surgically diagnosed inguinal hernias,

and 70 physically active controls without any history of connective

tissue disease and hernia were recruited for this case–control genetic

association study. This study employed multiplex Polymerase chain

reaction (PCR) method in combination with the next generation

sequencing for WT1 SNP genotyping (rs10835894, rs11031762,

rs11031779, rs1799925, rs2301251, rs3809060, rs5030178 and

rs7925851).

Results: There are no statistically significant differences of sex,

hernia type, malignancy history between cases group and controls

group. Significantly, more patients gave a positive family history for

an inguinal hernia compared to healthy controls (OR 3.635, 95% CI

1.364–9.660, P = 0.007). All the SNPs in two groups conformity with

Hardy–Weinberg equilibrium. WT1 SNP (rs7925851) was identified.

Our results revealed an increased frequency of WT1 rs7925851 AA

genotype in inguinal hernia patients (OR 1.704, 95% CI 1.114–2.605,

P = 0.049). Moreover, Allele G of rs3809060 could be a risk allele for

inguinal hernias (OR 2.084, 95% CI 1.236–3.516, P = 0.006).

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S61 Hernia (2019) 23 (Suppl 1):S50–S100

Conclusions: This study confirmed that polymorphism of the WT1 is

associated with an increased risk for developing inguinal hernias in

Chinese Han population. Therefore, rs3809060 and rs7925851 locus

may play key roles in molecular mechanism of inguinal hernia

pathophysiology.

P-1062

Endometriosis and hernia: a ‘‘Hidden’’ source of pelvic

pain and the multi-disciplinary role of pelvic physical

therapy

Sarrel SSallie Sarrel PT ATC DPT

Endometriosis is a condition in which tissue similar to but not the

same as the lining of the uterus is found throughout the pelvic cavity.

176 Million women worldwide experience symptoms which may

include heavy bleeding, excessive menstrual cramps, abdominal,

back, and leg pain, urinary issues and painful sex. Pelvic Physical

Therapy is a sub specialty of physical therapy focused on the hip,

lower abdomen, and pelvis from the bones, to the muscles, including

the pelvic floor, to the nerves and fascia. Ongoing pelvic pain post

excision of endometriosis by a gynecology specialist may be treated

by a pelvic physical therapist. In 1 year, in a private, single practi-

tioner, pelvic physical therapy practice specializing in post excision

of endometriosis issues, 14 occult, or no bulge, hernias were identified

as ongoing sources of pelvic pain. The pelvic physical therapist was

trained in multiple techniques to identify and treat ilioinguinal,

femoral and genitofemoral nerve symptoms. All 14 patients did not

have hernia seen in the retroperitoneal space during excision but

arrived to physical therapy with symptoms consistent with hernia. On

examination by an occult hernia general surgery specialist, all 14

were positive for no bulge hernias. Occult hernia may contribute to

pain during sex, genital pain, groin pain, pelvic floor pain, increased

lower abdominal pain during menstruation, perceived urinary pres-

sure and leg pain. Too often women have an ovary removed to treat

pain generated from these hernias. In the endometriosis patient hernia

may be missed during follow-up visits and surgery with the gyne-

cologist. As a driver in pelvic pain, occult hernia should become more

widely recognized as a source of pelvic pain in the general surgery

community. The Pelvic Physical Therapist and the General Surgeon

play a role in progressing the ongoing endometriosis pain patient as

part of a multi-disciplinary team.

P-1063

Surgical management during non-elective admission

for incisional hernia decreases readmission rate

in the national readmission database

Rives G, Beck W, Taylor J, Davis B, Bhavaraju A, Karim

S, Reif R, Sexton KUniversity of Arkansas for Medical Sciences

Management of non-elective admissions for incisional hernia is

variable. Patients are managed medically or surgically, a decision

where morbidity and symptomatology often guide treatment. While

surgery is the more definitive treatment, there is no widely accepted

guideline in treating incisional hernias. Although readmission data is

lacking, it was our goal using the data available to evaluate the rate of

readmission when comparing the two modalities. We hypothesized

that while increasing cost, surgical management would decrease

readmissions. Using the National Readmission Database, a

retrospective analysis was performed using univariate and bivariate

statistics comparing the management of non-elective admissions for

incisional hernia. There were 208,239 patients with non-elective

admissions. In comparison, 162,473 patients were managed medically

whereas 45,766 underwent surgical treatment. The average length of

stay was 6.1 days and 8.5 days for medical and surgical therapy,

respectively. The readmission rate was 19.3% for medical manage-

ment compared to 6.6% for those managed surgically. The Elixhauser

Readmission and Mortality Scores were 19.4/6.35 for medical therapy

and 12.2/3.8 for surgical therapy. In regard to costs, the total costs all

admissions were $68,175 for patients managed medically and $98,464

for those managed surgically. Of patients with initial medical therapy

that were readmitted (31,355), 1018 (3.25%) underwent operative

therapy on first readmission. An additional 4690 eventually under-

went an operation for 18.2% of the total readmitted population. Of

patients with initial surgical therapy that were readmitted (n = 3028),

52% (n = 1567) underwent an operation on their first readmission. In

conclusion, operative management of patients admitted non-electively

with incisional hernia decreases readmission rate and increases cost.

Furthermore, up to 18% of patients in the medical therapy group

eventually underwent operative therapy.

P-1065

Resilience and healing of a novel reinforced bioscaffold

(RBS) matrix in the setting of high-risk incisional

hernia repair after enterocutaneous fistula (ECF)

takedown

Awad S, Tran-Chao H, Lee D, Makris K, Chiu L, Becker

N, Gillory L, Chai CBaylor College of Medicine, MED VAMC

Purpose: Concurrent repairs of incisional hernias with mesh after

ECF takedown exhibit high surgical site infection rates (SSI). Syn-

thetic mesh is not routinely used. Reinforced BioScaffolds (OviTex

P 1S, 6 layers of sheep extracellular matrix interwoven monofilament

polypropylene) offer an alternative. We report the clinical course of a

patient who developed a SSI after ECF takedown with hernia repair

with OviTex RBS, and demonstrate the rapid incorporation of the

matrix with resultant skin grafting and complete healing.

Methods: A 66 year old male with O2 dependent COPD and severe

malnutrition underwent multiple laparotomies for duodenal perfora-

tion, small bowel resections and takebacks elsewhere with resultant

EC fistulas. He presented for ECF takedown and incisional hernia

repair. ECF takedown and retrorectus hernia repair with 20x20 cm

OviTex P 1S RBS was performed. 1 week postop, a deep SSI with

dehiscence of skin and anterior rectus sheath closures developed,

exposing the RBS. The RBS was left in place and wound care was

initiated with wet to dry followed by wound VAC placement.

Results: Contrary to other biologic and synthetic meshes in this

setting, RBS seamlessly and effectively incorporated within the

wound with rapid granulation. By 8 weeks, an excellent bed of tissue

that allowed for STSG had formed. The patient is 12 months postop

with a completely healed incision and no recurrence.

Conclusion: This is the first report describing RBS in AWR in a high

risk contaminated case. RBS was resilient to infection and allowed

robust wound healing and STSG more rapidly than other synthetic or

biologic scaffolds, without recurrence of the hernia. These results

may be due to the unique known effects of this ECM on wound

healing 1. Further study is warranted.

1. Ovine-Based Collagen Matrix Dressing: Next-Generation Collagen

Dressing for Wound Care, Advances in Wound Care, 2016, Vol. 5, #

1, pp 1–9

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Hernia (2019) 23 (Suppl 1):S50–S100 S62

P-1067

Does polypropylene mesh increases apoptosis in duct

deferens and testis? Experimental assay in rats

Damous S, Damous L, Miranda J, Birolini C, Montero E,

Utiyama EHospital das Clınicas da Faculdade de Medicina da Universidade de

Sao Paulo

Background: The impact of hernia repair in testicular function and

fertility remain uncertain. This study evaluated the duct deferens and

testicles of rats submitted to bilateral inguinotomy with mesh placing.

Methods: 60 male Wistar rats were distributed in three groups, in

according to the treatment: (1) control (C): only inguinotomy; (2)

MDD: mesh placed on duct deferens; and, (3) MSF: mesh placed on

spermatic funiculus. After 30 and 90 postoperative days the duct

deferens was collected in the site of mesh implantation. Two assays

for apoptosis evaluation were performed by immunohistochemistry—

cleaved casapase-3 and TUNEL. Results are expressed as percentage

of positively area.

Results: The apopstosis were similar on duct deferens in both assays

on 30 and 90 postoperative days (p[ 0.05). In the testis, there was no

difference for cleaved casapase-3 (p[ 0.05) however in the TUNEL

assay there was an increase in apoptosis after 90 days of surgery in

the both mesh groups (p\ 0.05 C vs. MDD and MSF).

Conclusion: Inguinotomy with mesh placing does not promote

apoptosis in the deferent duct of rats in the short and long term but in

the testicles increased apoptosis in the long term evaluation. Further

investigations are necessary to assess long-term testicular function

and the real impact on male fertility.

P-1069

Minimally invasive ventral hernia repair using

the ‘Venetian Blinds’ technique

Chan D, Ravindran P, Fan H, Talbot MSt George Hospital

Purpose: Ventral hernia repair utilising a ‘Venetian blinds’ technique

of plication in combination with mesh reinforcement, closes the

hernia defect and reduces risk of seroma formation. This totally intra-

corporeal technique avoids anterior abdominal wall incisions. Pre-

operative Botulinum toxin A (BTA) injections facilitates laparoscopic

suturing of the midline abdominal wall defect. In non-midline hernias,

defect closure can negate restricted lateral spaces which crowd mesh

fixation. This series demonstrates an early experience of using min-

imally-invasive ‘Venetian blinds’ technique in ventral abdominal

hernia repair.

Methodology: A single centre prospective case series was conducted

between April 2016 and December 2017 using the ‘Venetian blinds’

technique for repair of complex ventral abdominal hernias. Twelve

patients (7 midline, 5 non-midline) were involved in the study during

this time period. Midline ventral hernia patients received a dose of

BTA 4–6 weeks prior to surgery. Hernias were repaired with mini-

mally invasive ‘Venetian blinds’ technique, with synthetic mesh-

reinforcement (11 laparoscopic, 1 robotic).

Results: 12 patient (2 male, 10 females) with a mean age of 66.6 and

body mass index of 31.8 were included. Mean operation time 135 min

and length of stay of 4.75 days. Mean follow-up of 17.5 months

(range 4.6–28.6). No recurrence of hernia to date. Two patients

converted to a laparoscopic-open hybrid approach. One patient had an

infected seroma treated with antibiotics only. Another developed

pneumonia.

Conclusion: Minimally-invasive ‘Venetian blinds’ technique with

BTA is a novel and feasible technique for repair of complex ventral

hernias that reduces the potential for seromas and wound infections

overlying mesh placement.

P-1071

The impact of intraoperative Foley catheters

on postoperative urinary retention after inguinal hernia

surgery

Crain N, Tejirian TKaiser Permanente Southern California Medical Group

Indwelling urinary catheters, commonly known as Foley catheters

(FC), are often used during inguinal hernia operations; however, the

impact of intraoperative Foley catheter use on postoperative urinary

retention (POUR) is not well understood. We conducted a retro-

spective study on 27,012 inguinal hernia operations across 15

Southern California Kaiser Permanente medical centers over

6.5 years. We focused on unplanned returns for POUR to the urgent

care (UC) or emergency department (ED) within the first postopera-

tive week. In total, 239 (0.85%) patients returned to UC/ED with the

primary diagnosis of POUR, majority being male [235 (98%) men vs.

4 (2%) women]. Overall, there was a higher rate of UC/ED returns for

POUR for older patients, as observed between the age groups\ 50,

50–65, and[ 65 years old [0.27, 0.68, and 1.65%, (p\ 0.00001)].

There was a higher incidence of POUR in open repairs utilizing

general anesthesia vs. local with monitored anesthesia care [0.7% vs.

0.3%, (p\ 0.0001)]. Laparoscopic inguinal operations comprised

5017 of the total operations, 28% of which had intraoperative FC use.

While the incidence of POUR was greater in laparoscopic vs. open

inguinal hernia repair [2.21 vs. 0.58%, (p\ 0.00001)], there was no

difference in POUR returns when comparing intraoperative FC vs. no

FC use in the laparoscopic approach [2.36% vs. 2.15%, (p = 0.33)].

For all laparoscopic operations, there was no difference when com-

paring intraoperative FC vs. no FC use in urinary tract infection

within 7 days [0.8 vs. 0.6%, (p = 0.28)] and 30 days [1.7 vs. 1.5%,

(p = 0.28)]. Only one patient returned with a bladder injury following

a bilateral laparoscopic hernia repair with no FC use. POUR can be

minimized by avoiding general anesthesia for open inguinal hernia

repairs, however intraoperative Foley catheter use does not affect

POUR or UTI rates for laparoscopic repair.

P-1072

An analysis of early postoperative returns after inguinal

hernia surgery

Crain N, Tejirian TSouthern California Kaiser Permanente Medical Group

Although inguinal herniorrhaphy is low risk, patients still return to the

urgent care or ED. We performed a retrospective study on 19,296

inguinal hernia operations across 14 Southern California Kaiser

Permanente medical centers over 5 years. Unplanned returns within

the first postoperative week were evaluated focusing on four poten-

tially avoidable diagnoses (AD): pain, constipation, urinary retention,

and nausea/vomiting. Overall, 1370 (7%) patients returned to the

urgent care/ED, of which 537 (39%) had an AD. There was no dif-

ference in total returns [7.1 vs. 7.4%, (P = 0.33)] or AD returns [2.8

vs. 2.6%, (P = 0.44)] for males vs. females. Of the 537 total AD

returns, there were 205 (38%) patients with pain, 191 (36%) with

urinary retention, 112 (21%) with constipation, and 29 (5%) with

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S63 Hernia (2019) 23 (Suppl 1):S50–S100

nausea/vomiting. Most AD returns (78%) occurred within the first

three postoperative days. Pain was greater in open operations [44 vs.

26%, (P\ 0.05)], and urinary retention was greater in the laparo-

scopic group [27 vs. 55%, (P\ 0.05)]. The overall rate of return was

higher for laparoscopic compared with open unilateral operations [8

vs. 6% (P\ 0.05)], but similar between approaches for bilateral

operations [11 vs. 10%, (P = 0.32)].

P-1073

The establishment, development and preliminary data

analysis of chinese hernia registry

Qin C, Shen Y, Chen JBeijing Chao-Yang Hospital, Capital Medical University

The introduction of the tension-free hernia repair concept open a new

chapter for Chinese hernia surgery. Since 1997, we experienced

20 years of dramatic development with fruitful achievement,

including implementation of new surgical techniques and medical

devices, experiences accumulation and establishment of treatment

guidelines. Now, more than 1.5 million inguinal hernia procedures

and around 150,000 abdominal wall hernia operations are carried out

each year. However, China is such a vast country with imbalanced

development. The quality of medical care in hernia surgery is not

uniform due to various kinds of irregular operations. How to change

this situation? Hernia registry is an application-oriented outcome

research tool which could monitor and evaluate our daily clinical

practice, ultimately, investigate its effectiveness (outcome research).

Many hernia societies in European and American nations have built

up their own hernia database. Great quality improvement has been

achieved. The successful experience of Germany hernia database—

Herniamed, is worth learning and introducing. Follow the example of

Herniamed, we designed a new Internet-based Chinese and English

bilingual registry system. Via the Internet, all relevant patient data

(comorbidities, previous operations, staging, specific surgical tech-

nique, medical devices used, perioperative complications and follow-

up data) can be entered into this registry database, meanwhile some

special issues are added according to Chinese national conditions,

especially the issues have not been clarified or still remain contro-

versial in the latest guidelines. Up to now, more than 180 hernia

centers nationwide were volunteer to join the Hernia Registry in

China in the past 6 months, and more than 28,000 pieces of hernia

diseases data have been collected and recorded in Chinese Hernia

Registry. The prototype of the Internet based Chinese hernia database

has been established, with this framework was built and participants

were enrolled, we believe this system will provide continuous

improvement for Chinese hernia surgery.

P-1074

Mini- or less open sublay (MILOS) repair for incisional

hernias: the Creighton experience

Schroeder A, Tubre D, Reinpold W, Fitzgibbons RCreighton University Medical Center

Introduction: Retrorectus mesh placement is widely accepted as the

gold standard for the repair of incisional hernias. The open procedure

requires an extensive abdominal wall dissection but has the advantage

of extraperitoneal mesh placement. Laparoscopic intraperitoneal

onlay mesh (IPOM) repair avoids the extensive dissection and is

associated with less surgical site infections, however the intraperi-

toneal mesh placement can result in a variety of adverse outcomes.

Recently a hybrid operation, termed the MILOS (mini/less open

sublay) technique has been described by Dr. W. Reinpold (Hamburg,

Germany). We present preliminary data from an ongoing study at

Creighton University Medical Center (CUMC) comparing MILOS

repair to laparoscopic IPOM repair.

Methods: Dr. Reinpold personally demonstrated the first two MILOS

procedures at our institution. Subsequent procedures were performed

independently. Patient data and outcomes from MILOS repairs and

laparoscopic IPOM repairs are collected prospectively. An enhanced

recovery after surgery (ERAS) protocol is utilized to reduce opioid

use. Follow up is carried out at 2 weeks, 6 months, and 12 months.

Results: Seven MILOS repairs and 9 laparoscopic IPOM repairs have

been performed since January 2018. The two groups were comparable

in terms of patient characteristics and included mostly midline inci-

sional hernias. Hernia size (mean 48.6 cm2 vs. 18.2 cm2, p = 0.04)

and mesh size (mean 410.4 cm2 vs. 175.4 cm2, p = 0.0002) were

larger in the MILOS group. Hospital stay was slightly shorter in the

laparoscopic IPOM group (mean 2.3 days vs 1.0 days, p = 0.06).

There was no difference in the morphine equivalent dose (MED) in

the two groups (mean 3.4 mg vs. 6.2 mg, p = 0.46). There were no

immediate complications or recurrences.

Conclusion: Our initial experience with the new MILOS technique

indicates its reproducibility and safety in large incisional hernias. This

is an ongoing study and results will be updated as the sample size

increases.

P-1076

Racial disparities are prevalent in laparoscopic

utilization for inguinal hernia repair

Mitchell A, Harner A, Drevets P, Allen G, Zakaud Dakaud

A, Hilton L, Holsten SAugusta University

Introduction: Laparoscopic inguinal hernia repair has gained wide-

spread adoption throughout the United States. The known benefits of

the procedure include lower community costs, lower postoperative

pain, quicker recovery, and reduction in chronic pain. Recent inter-

national society guidelines suggest that a majority of patients are

candidates for laparoscopic repair, and increased utilization has been

seen over the past few years. We aimed to determine if patient race

had any impact on receiving a laparoscopic repair.

Methods: The 2011–2015 NSQIP databases were individually quer-

ied for the CPT codes 49505, 49507, 49520, 49521, 49651, and

49652. Univariate and multivariate analyses were conducted with

‘‘Laparoscopic Surgery’’ as the primary endpoint. Race, age, gender,

and comorbidities were analyzed to determine if there were any

significant disparities between different populations. Subgroup anal-

yses were conducted in the 2015 cohort.

Results: On initial review, African American patients were more

likely to receive a laparoscopic repair when compared to Whites (OR

1.14, 1.04–1.25, p = 0.0048). Multivariate analysis showed an

opposite relationship (OR 0.80, 0.71–0.90, p = 0.0001). Subgroup

analyses showed that African American men (OR 0.71, 0.62–0.81,

p\ 0.0001) and White women (OR 0.48, 0.40–0.58, p\ 0.0001)

were significantly less likely to undergo laparoscopic repair when

compared to White men and African American women, explaining

the univariate and multivariate findings. Other factors with a signifi-

cant impact on laparoscopic utilization included ASA class, bleeding

disorders, age, weight, gender, diabetes, and Asian race (OR 0.43,

0.31–0.58, p\ 0.0001). The disparities were present throughout all

cohorts.

Conclusion: Racial disparities are extremely prevalent in utilization

of laparoscopic inguinal hernia repair. Surgeon judgment alone in

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Hernia (2019) 23 (Suppl 1):S50–S100 S64

determining if laparoscopic repair should be offered may be flawed,

and we suggest instituting protocols to eliminate racial disparities in

laparoscopic utilization.

P-1077

Incisional hernia repair with self-expanding

polypropylene mesh

Martins de Oliveira Neto R, Roberto Puglia C, Roberto

Corsi P, Soares Gallo A, Fernando Rodrigues Alves de

Moura LHospital Samaritano de Sao Paulo, Americas Servicos Medicos

Incisional hernias still represent a challenge to the surgeons, espe-

cially the large—complexes ones. Several methods are been proposed

and used, with very different results achieved. In the field of the open

approach the most common complications are the occurrence of

‘‘seromas’’ due to the subcutaneous dissection, infections, pain and

recurrence. The author presents the initial experience with the Self-

expanding polypropylene mesh. The unique design and technique of

this mesh, offer patients the benefits of an intraabdominal repair,

while offering surgeons the ease of an open anterior approach, with

the added ability to use mechanical fixation. The parietal side is

constructed of two layers of monofilament polypropylene mesh,

providing rapid tissue ingrowth and strong incorporation into the

abdominal wall. The visceral side is made of submicronic ePTFE,

which provides a permanent barrier minimizing tissue attachment. In

our first series of 10 patients with complexes hernia, the results were

very promising and encouraging. We notice no complications such as

‘‘seromas’’ or recurrence, and less pain referred by the patients.

P-1078

Robotic inguinal herniorrhaphy: initial experience




The robotic surgery provided the surgeon with refinement of move-

ments, delicacy in maneuvers and procedures, visualization with

better definition in three dimensions and ergonomics for the surgeon.

The authors present their initial experience in the treatment of ingu-

inal hernia with robotic surgery. In this initial experiment, 15

procedures were performed. All procedures were performed by the

same technique as performed by the laparoscopic route, except for the

fixation of the mesh, which was performed with suture. There were no

intercurrences. Surgical time was higher in the first procedures, but

presented a substantial decrease over the others. All patients were

discharged the day after the procedure. There was a marked reduction

of the postoperative pain in patients submitted to robotic inguinal

herniorrhaphy. The authors conclude from this initial experience that

robotic inguinal herniorrhaphy is feasible, safe and it is a quick

learning method for the surgical team.

P-1079

Cosmetic umbilical/ventral hernia repair

Meknat A, Rimpel B, Greenberg YBrookdale University Hospital and Medical Center

There are a variety of approaches when it comes to umbilical hernia

(UH) repair. Cosmetic results take a backseat with conventional open

UH repairs often leaving an undesirable scar. With smaller and less

central incisions, laparoscopic UH repair is a preferred modality for

cosmetic results given similar efficacy with respect to recurrence

rates. But even the laparoscopic repair has its cons: multiple incisions

beyond the umbilicus. We describe our technique of open UH repair

utilizing a single trans-umbilical incision. Special emphasis is placed

on creating flaps and dissecting the subcutaneous tissue free from the

umbilical stalk. This meticulous dissection allows for a more cos-

metically pleasing closure, leading to greater patient satisfaction.

A vertical trans-umbilical incision is made using a #15 blade.

Continuing with the same blade, skin flaps are raised, carefully sep-

arating the umbilical skin from the underlying hernia sac. The sac is

carefully dissected free from surrounding subcutaneous tissue. Next,

the sac is opened and the content reduced into the peritoneal cavity.

The hernia sac is then excised. Standard of care is applied when it

comes to determining the type of fascial closure. A mesh is used if the

defect is greater than 3 cm, given the patient does not have ascites, in

an inlay fashion. Otherwise, the defect is closed with #0 Vicryl suture

in a figure of eight fashion. The superior cosmetic results come from

placing three sub-dermal stitches through one flap end, anchoring

them to the underlying fascia, and coming back out through the other

flap’s sub-dermal layer in an interrupted fashion. This ultimately

recreates the umbilicus in a cosmetically pleasing way. 4-0 Biosyn is

then used to re-approximate the remaining skin. Xeroform and a

compression dressing are placed into the re-created umbilicus.

This technique is easy to perform, has similar efficacy to any other

technique,

P-1080

Current practice patterns for primary umbilical hernia

repair in the United States

Koebe S, Greenberg J, Huang L, Phillips S, Lidor A, Funk

L, Shada AUniversity of Wisconsin School of Medicine and Public Health

Introduction: The approach to primary umbilical hernia (PUH) repair

varies depending on hernia size, patient age, sex, BMI, comorbidities,

and surgeon technique. Of these, only hernia size has been widely

studied. This study evaluates umbilical hernia repair technique with

respect to several patient characteristics. We hypothesize that the

approach to repairing umbilical hernias will vary with BMI, age, and

sex.

Methods: A retrospective study was performed using data from the

prospectively maintained Americans Hernia Society Quality Collab-

orative. All patients undergoing elective, clean PUH from 2013 to

2018 were identified. Patient characteristics were compared using

Pearson’s test or Wilcoxon rank sum test. Multivariate logistic

regression was performed to assess the independent effect of BMI,

age and sex on mesh use.

Results: 3475 patients were included. Seventy-four percent of

patients were male. Men undergoing PUH were older (54.1 vs.

45.8 years, p\ 0.001), with a higher BMI (31.6 vs 30.2, p\ 0.001).

Hernia defect size was similar. Mesh was used more commonly in

men (67% vs 60%, p\ 0.001). An open approach was more common

than laparoscopic/robotic (75% vs. 25%, respectively). Use of

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S65 Hernia (2019) 23 (Suppl 1):S50–S100

laparoscopic/robotic approach increased with BMI and hernia size but

was not associated with age or sex. Mesh was used in 33% of

repairs B 1 cm, and 82% of repairs[ 1 cm in size (p\ 0.001). On

multivariate analysis, mesh use was associated with increasing hernia

width (OR 5.5, CI 4.7–6.3) and BMI (OR 1.8, CI 1.5–2.1) but not age

or sex.

Conclusion: The majority of PUH are performed open. Despite

umbilical hernias being more common in women, the majority of

those undergoing repair in our dataset are male. BMI and hernia size

influence operative technique including mesh use for PUH, but age

and sex do not. Most over 1 cm in diameter are repaired with mesh.

This suggests an opportunity for development of better guidelines to

standardize mesh use for PUH.

P-1081

Robotic abdominal wall hernias treatment: initial

experience




Abdominal wall hernias represent a common condition in surgical

practice. They may present as simple or sometimes extremely com-

plex cases the laparoscopic surgical treatment is consecrated and

widely used today with excellent results. The advent of robotic sur-

gery, or assisted by the robot, allowed the surgeon to use a more

meticulous and ergonomic platform, which can bring advantages in

the treatment of complex cases. The authors present their initial

experience with abdominal wall hernias treated with the robotic

platform. Nineteen procedures were performed. They consisted in 15

inguinal hernias and 4 ventral hernias (incisional ones). We used our

routine surgical technique in all cases. All the procedures were per-

formed without any intraoperative intercurrences. All patients were

discharged the day after the procedure was done. The most important

characteristic observed was the significant decrease in postoperative

pain. We conclude that this is a promising and safe method for the

treatment of abdominal wall hernia cases.

P-1082

Ventral hernia: surgical treatment with robotic

platform, initial experience




Among the abdominal wall hernias, ventral hernias represent an

important and common part of daily surgical practice. It can range

from small umbilical hernia to large and complex incisional hernias,

which can cause severe physical disabilities to patients and even

potentially life-threatening complications. Among the techniques

used, surgeons have a range of open or laparoscopic procedures, with

or without the use of prostheses, with the most different results. The

robotic platform provided the surgeon with a meticulous and detailed

technique through fine movements and three-dimensional vision of

high definition, besides a very favorable ergonomics. Within the

authors’ initial experience with the robotic platform, we performed

some cases of ventral hernias. Our initial experience consisted of 4

cases of patients with ventral hernia. Of these, three patients had

complex incisional hernias and one patient had an important

endometriotic lesion of the anterior musculature, associated with

hernia in a previous C-section scar. All patients underwent robotic

surgical treatment without complications. We Used suture to perform

the fixation of the mesh in all cases. All patients were discharged the

day after the procedure. The patients evolved without complications

and with a marked decrease in postoperative pain. We observed that

the superiority of the robotic platform for performing the surgical

procedure was striking. We conclude that, although still in initial

experience, the robotic platform is extremely promising for the

treatment of complex ventral hernias.

P-1084

The Ramirez ‘‘Component Separations’’ method

for closure of large abdominal defects modified by mesh

augmentation: early postoperative outcome of 84

patients in our hospital

Ceno M, Paul D, Kottmann T, Berger DKlinikum Mittelbaden Baden–Baden

Introduction: This study presents an overview about the early post-

operative outcome of 84 patients who underwent a big incisional

hernia operation repair using the component separations technique of

Ramirez with additional mesh augmentation.

Materials and methods: In the period from 2003 to 2014, 84 patients

with complicated incisional hernia and recurrent hernia of the

abdominal wall, were surgically treated in our department using

Ramirez-modified component separation by additional augmentation

of the abdominal wall with non-resorbable mesh. In our prospective

study, all 84 patients underwent a postoperative examination and the

risk factors for the wound healing disorder were identified and have

been statistically analyzed.

Results: The median age of the patients was 64 years. At the time of

surgery 89% of the patients were over 49 years old. In between

n = 84 patients who underwent surgery where 40% female (n = 33)

and 60% male (n = 51) patients. The median BMI of our patients was

31. The majority of patients was assigned to ASA class 2. The rate of

the primary ventral hernia was 58.3% (n = 49). The mean hernia size

was 13.6 cm. The operations were all performed by a single surgeon.

The results of the follow-up during 120 days after operation and the

statistical analysis for the evaluation of possible risk factors for

wound healing disorder are presented. Wound healing is evaluated

according to Hernia Ventral Group 2004 and the postoperative

complications according to the Clavien-Dindo classification.

Conclusion: The posterior component separation with additional

mesh implantation is a feasible option for repairing giant primary and

recurrence hernia of the abdominal wall.

P-1085

Ovine polymer-reinforced bioscaffold in abdominal

wall reconstruction

Sawyer MComanche County Memorial Hospital

Introduction: Abdominal wall reconstruction (AWR) techniques are

increasingly used for incisional herniorrhaphy. This series describes

the use of ovine polymer-reinforced bioscaffolds (OPRBS) for repair

augmentation in AWR.

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Hernia (2019) 23 (Suppl 1):S50–S100 S66

Methods: Retrospective review was conducted of a consecutive series

of 23 patients in whom OPRBS was utilized to augment AWR with

myofascial advancement flaps. Demographic, perioperative, and fol-

low-up data were analyzed.

Results: There were 13 female and 10 male patients. Fifteen had

recurrent hernias (65.2%). Mean age was 60.8. Mean BMI was 33.3.

Comorbidities included obesity (60.1%), hypertension (56.5%), pre-

vious wound infection (39.1%), diabetes mellitus (34.8%) and recent

smoking history (26.1%). Mean Ventral Hernia Working Group grade

was 2.8 ± 0.8. There were eight Grade 3 and five Grade 4 patients.

Enterocutaneous fistulae were present in all Grade 4 patients, two of

which were through synthetic mesh. Concomitant procedures were

performed in 11 patients (47.8%). These included small bowel

resection in three, enterocutaneous fistula resection with associated

small bowel in three, colon resection in one, gastric bypass reversal in

one, and panniculectomy in three. Synthetic mesh was removed in 11

patients (47.8%), and biologic matrix in two. Transversus abdominis

release was performed in 78.3% and anterior release in 21.7%.

OPRBS was placed in the retrorectus space (82.6%), as IPOM

(13.0%) or as onlay (4.4%). Mean follow-up was 13.2 ± 8.0 months

(range 4–27). There were two hernia recurrences (8.9%). Wound-

related complications occurred in 7 patients (30.4%), including four

superficial infections, two seromas, and one superficial wound

necrosis. These were all effectively treated without the need for

removal of OPBRS.

Discussion: Early experience with OPRBS in AWR is encouraging in

this challenging patient population. OPRBS possesses salutary prop-

erties of both biologic, and synthetic materials. Long-term follow-up

and larger study populations are needed to confirm these findings.

P-1086

The results of using extended totally extraperitoneal

repair (eTEP) for ventral hernias: our experience

Akhmetov A, Kashchenko V, Lodygin A, Mitsinskaya A,

Mitsinskii MThe L.G. Sokolov Memorial Hospital 122

Introduction: There was the first reference about eTEP Sublay for

ventral hernias in 2017. 75 patients were followed by during 1 year in

5 centers.

Materials and methods: Our study includes 11 patients (the mean

age 55.3, BMI 34.6, ACA 2): 4—with large umbilical or epigastrium

hernia, 4—with umbilical hernia and diastasis recti abdominis and

3—with recurrent ventral hernia. All patients had preoperative com-

puter tomography. Two methods were used: ‘‘upper’’ technique—6

and ‘‘lower’’ technique—5 patients. After entering to the retromus-

cular mesh placement (position of ports was chosen according to the

technique), the dissection was performed with the help of the balloon,

then additional ports were set. Then we made total tissue dissection

(Rives Stoppa) from ensiform process to the pubis, with the excision

of the hernial sac. We stitched up the white line of the abdominal

cavity layer by layer. The defects of the lower part of anterior

abdominal wall were also tightly stitched up. Polypropylene mesh

‘‘medium hardness’’ was fixed in 9 and ‘‘easy’’—in 2 cases. It was

fixed two seams in one case, there were no fixation in other cases. We

drained the retromuscular mesh placement for 1 day.

Results: 2 patients had seroma (type 1), there were no repeated sur-

gery and common complications. We used EuraHS QoL scale for

assessment quality of life: the chronic pain—1, there is no movement

limitation.

Conclusion: Using the ‘‘new’’ technique eTEP for ventral hernias is

possible in conditions of herniological centre equipped with

endovideosurgical instruments. Early and relatively long-term results

show the high efficiency and good cosmetic result.

P-1087

What are the indications of the posterior separation

component hernia repair for ventral hernias?

Akhmetov A, Kashchenko V, Lodygin A, Mitsinskaya A,

Mitsinskii MThe L.G. Sokolov Memorial Hospital §122

Relevance: Posterior separation component hernia repair are used

only in some clinics in Russian Federation. We mean TAR (by

Novitsky) as well as PSCT (by Carbonell). The indications of these

types of surgery are discussed.

Materials and methods: There were 385 patients with epigastric and

large umbilical hernias: 29% of patients with W2-7.5% needed pos-

terior separation component hernia repair. 112 patients had

preoperative computer tomography, respiratory function, banding in

order to minimize the SAG. Four patients had the lateral localization

of hernias. We made the standardized PSCT. We did not drain the

retromuscular mesh placement, only the hernia sac subcutaneously for

1 day. When it was the lateral position of hernia, we extracted the

defect after TAR, sewed from the two sides, it was necessary to set

polypropylene mesh type Progreep (self-locking) in one case.

Results: Postoperative course was the same as after ‘‘sublay’’ tech-

nique: the same number of bed-days and frequency of the

complications. We had 1 seroma type 1 requiring no surgical cor-

rection—we prefer the puncture and controlling ultrasonography in

dynamics—fifth day after surgery. There were no early relapses.

Patients were followed during 1 year and recorded in the hernological

registry ‘‘Hernia-lab’’. There were no infectious complications and no

late relapses.

Conclusion: Using preoperative SCT helps us to choose the optimal

variant of the surgery. When W2 is 8 cm and W2 is less than 6–8 cm,

in the conditions of intraoperative evaluation, and if the abdominal

pressure is reduced to a significant tension of the tissues, it is nec-

essary to use PSCT. Lateral or parastomal hernias are also the

important conditions of this type of surgery.

P-1088

Is young age a risk factor for chronic postoperative

inguinal pain (CPIP) after endoscopic totally

extraperitoneal (TEP) repair?

Bakker W, van Hessen C, Verleisdonk E, Clevers G,

Davids P, Schouten N, Burgmans IDiakonessenhuis Utrecht

Purpose: A generally known risk factor for developing chronic

postoperative inguinal pain (CPIP) after inguinal hernia repair is

young age. However, studies discussing young age as a CPIP risk

factor are mainly based on open repairs. The aim of this study is to

determine if young adults (age 18–30) are also more prone to expe-

rience CPIP after totally extraperitoneal (TEP) inguinal hernia repair,

compared to older adults (age C 31).

Methods: A prospective study was conducted in a high-volume TEP

hernia clinic in 919 patients. Patients were assessed preoperatively, at

3 months, 1 year and 2 years after TEP mesh repair. The primary

outcome was clinically relevant pain (NRS 3–10) in young adults

compared to older adults at 3 months follow-up. Secondary outcomes

were pain 1 and 2 years postoperatively, the impact of pain on daily

123

S67 Hernia (2019) 23 (Suppl 1):S50–S100

living, foreign body feeling and testicular pain. Furthermore, age-

categories were analyzed to determine potential age dependent CPIP

risk factors.

Results: Follow-up was completed in 867 patients. No significant

difference was found between young adults and older adults for

clinically relevant pain at 3 months follow-up (p = 0.723). At all

follow-up time points no significant differences were found for

clinically relevant pain, any pain (NRS 1–10), mean pain scores, the

Inguinal Pain Questionnaire (IPQ) and the Carolina Comfort Scale

(CCS). The subgroup analyses showed no age dependent risk factor

for CPIP development.

Conclusion: Young age is not associated with a higher risk of CPIP

after endoscopic TEP hernia mesh repair, which justifies this tech-

nique in patients 18–30 years of age.

P-1090

Comparison of laparoscopic totally extraperitoneal

inguinal hernia repair (TEP) and lichtenstein repair

in terms of sexual, sensory, quality of life and urinary

functions

Iscan Y, Sahan C, Agca B, Karip B, Memisoglu KFatih Sultan Training and Research Hospital

Introduction: Many studies have shown that laparoscopic inguinal

hernia surgery is more advantageous than open surgery. The purpose

of this study is to reveal the differences between the two different

methods in terms of sexual, sensory, quality of life and urinal results.

Materials and methods: Between July 2017 and January 2018,

sexually active 42 male patients were randomized by laparoscopic

total preperitoneal method (TEP) and Lichtenstein method (LCH)to

perform inguinal hernia repair. Patients were evaluated preopera-

tively, at 1st and 6th months postoperatively by the International

Sexual Function Index (ICIEF),International Prostatic Symptom

Score, AS, BECK Depression Scale, Inguinal Region Discrimination

Test (DT),DN4 Neuropathic Pain Questionnaire, FSH, LH and Total

Testosterone levels and SF-36 were assessed.

Results: Patients with a mean age of 49.86 ± 11and a BMI of

25.51 ± 2.84 were randomized into two groups as LCH (20) and TEP

(22).There was no significant statistically difference between the two

groups in terms of FEVA, IPSS and VAS. There was no significant

difference between the two groups in preoperative and postoperative

1st month in BECK depression scale. But in 6th month in LCH group,

BECK levels were statistically significantly higher when compared

with TEP group. At the 1st and 6th month DT, the measurements in

the LCH group were found to be statistically higher than the TEP

group. At the 1st and 6th months after the operation, DN4 values were

found to be significantly higher in the LCH group compared to the

TEP group. In uroflowmeter analyzes There was no difference

between the groups. However, reductions in urine volume in the TEP

group were statistically significant. In the SF36 analysis, the LCH

group showed statistically significant lower physical activity potential

and energy-vitality-vitality values at postoperative 6th month.

Conclusion: In terms of sexual function, urodynamics and pain, TEP

did not show any advantage for LCH. The LCH method was disad-

vantageous in neuropathic pain and discriminant analysis. In terms of

quality of life, the results of the TEP method are more pleasant.

P-1091

Incidence of asymptomatic inguinal hernias

as an incidental finding

van Hessen C, van Hessen C, Bakker W, Verleisdonk E,

Sanders F, Burgmans JDiakonessenhuis Utrecht

Introduction: An inguinal hernia is a clinical diagnosis. Only in case

of clinical doubt, ultrasound may be required. However, in day-to-day

practice this modality is often requested for men with groin com-

plaints. In some cases an incidental inguinal hernia is found with an

alternative cause for groin complaints. Studies on the prevalence of

asymptomatic inguinal hernias as an incidental finding among healthy

men have never been published.

Methods: This observational study consisted of a cross-sectional

analysis of groin ultrasound. The target population for this analysis

involved healthy men (ASA I or II) between 40 and 65 years old, with

a Body Mass Index\ 40 and without groin complaints or a medical

history of inguinal hernia. After signing the informed consent, a groin

ultrasound was made of both groins under Valsalva maneuver and

scored positive or negative by a specialized ultrasound technician, in

consultation with the radiologist.

Results: A total of 100 patients underwent groin ultrasound. In 10

patients (10%) an unilateral inguinal hernia was found. There were no

other findings in this study population.

Conclusion: In 10% of healthy men without groin complaints,

ultrasound shows an inguinal hernia. Hence, the chance that groin

complaints are wrongly attributed to an incidental inguinal hernia

found on ultrasound, appears to be considerable.

P-1092

One-stop routing for surgical interventions; a cost-

analysis of endoscopic groin repair

van Hessen C, van Hessen C, Roos M, Frederix G,

Verleisdonk E, Clevers G, Davids P, Burgmans JDiakonessenhuis Utrecht

Purpose: Single visit totally extraperitoneal (TEP) inguinal hernia

repair is an efficient service without impairment of safety or com-

plication rate. Data on the economic impact of this approach are rare.

The aim of this study was to compare the costs between the single

visit (SV) TEP and the regular TEP in an employed healthy popu-

lation from a hospital and societal point of view.

Methods: Retrospectively collected hospital costs and prospectively

collected societal costs were obtained from patients treated between

July 2016 and January 2018. Outcome measures consisted of all

documented institutional care, productivity loss and medical

consumption.

Results: For analysing the hospital costs a total of 116 SV patients

were matched to 116 regular patients. The hospital costs of a mean

SV patient were €1148.78 compared to €1242.84 for a regular patient,

with a mean difference of €94.06. Prospective analyses of 50 SV

patients and 50 regular patients demonstrated higher societal costs for

a mean regular patient (€2188.33) compared to a mean single visit

patient (€1621.44). The mean total cost difference between a SV TEP

repair and a regular TEP repair equaled €660.95 corresponding to a

19.3% decrease in costs.

Conclusions: This comprehensive cost-analysis showed that in an

employed, healthy population, the single visit TEP repair outprices

the regular TEP repair, with savings of €660.95 per patient, reflecting

a 19.3% decrease in costs. This routing is mainly interesting from a

123

Hernia (2019) 23 (Suppl 1):S50–S100 S68

societal point of view as the difference is mainly impacted by a

decrease in societal costs.

P-1094

Accelerated neutral atom beam (ANAB) treatment

of polypropylene mesh increases tissue integration

and reduces bacterial attachment

Khoury J, Kirkpatrick S, Phok B, Shashkov DExogenesis Corp

Prosthetic meshes are commonly used in the repair of abdominal wall

hernias. Meshes firmly reinforce the weakened area and provide

tension-free repair that facilitates the integration of surrounding tis-

sues. However, complications with the mesh relating to infection,

fibrosis, adhesions, mesh rejection, and hernia recurrence remain

high. An ideal mesh would be inert, resistant to infection, able to

maintain long-term tensile strength, rapidly integrate into the host

tissue, and remain flexible. Modifications of polymer weight and

mesh pore size have shown minor improvement in reduction of

infection and increased tissue integration; however, major improve-

ments are still required. In this study, we tested NanoAccelTM argon

(Ar) based ANAB treatment to modify the surface of polypropylene

(PP). ANAB utilizes accelerated clusters of Ar ions which are then

dissociated, and clusters electromagnetically removed. The resulting

neutral Ar atoms collide with a surface and cause mechanical and

physical changes without chemical modifications. Using PP coupons

and surgical mesh (Chirag Meditech), we treated the surface and

measured ability of normal human fibroblasts to attach and proliferate

(MTS assay); ability of P. aeruginosa bacteria to attach and begin

colonization (cell count); and mechanical strength of the mesh (In-

stron). Results show that absorbance of MTS increases from

0.135 ± 0.020 for control to 0.211 ± 0.018 for ANAB treated PP

(p\ 0.0027), indicating a significantly increased cell attachment and

proliferation. Bacterial attachment at 3 h decreased from

1267.4 ± 683.0 bacteria on control to 117.2 ± 25.1 on ANAB-trea-

ted PP, at least a tenfold reduction (p\ 0.0056). Tensile strength,

however was not affected (p = 0.247), maintaining strength and

flexibility. Taken together, this indicates that ANAB-treatment of

polypropylene mesh may result in significantly improved integration

with reduced risk of bacterial attachment.

P-1100

Intermittent small bowel volvulus following robotic

transabdominal preperitoneal hernia repair: a rare

complication caused by the barbed suture

Gupta A, Arguello-Angarita M, Glanville J, Mazpule G,

Pereira S, Rosenstock AHackensack University Medical Center

Case presentation: A 68-year-old male patient presented with

1 week of intermittent right lower quadrant abdominal pain, 1 month

after robot-assisted laparoscopic transabdominal preperitoneal

(TAPP) repair of right inguinal and umbilical hernias. A computer

tomography (CT) scan of the abdomen showed swirling of small

bowel mesentery—a finding concerning for an internal hernia. A

diagnostic laparoscopy was performed to further evaluate the etiology

of his abdominal pain. Intra-operatively, terminal ileum was found to

be adherent to the tail of a barbed absorbable suture that was used to

close the peritoneum following the patient’s hernia repair. A short tail

of the suture had been left and had become adherent to the bowel,

causing the bowel to rotate around this point. The distal portion of the

suture was cut flush to the bowel, and the proximal portion of the

suture was cut flush to the peritoneal flap. The bowel was untwisted

and returned to its normal position. The patient’s postoperative course

was uneventful, and he was discharged the following day.

Discussion: In recent years, surgeons have been using knotless, bar-

bed suture more often, especially in laparoscopic and robotic inguinal

and ventral hernia repairs. Although rare, similar complications (e.g.

small bowel obstruction, volvulus) caused by the barbed suture have

been reported since its adaptation, especially in the context of

inframesocolic surgeries. The complication described above could

have been prevented by ensuring the tail of the suture was not

exposed. The case presented suggests that there can be unforeseen

complications with barbed suture and that direct exposure of the

bowel to this suture may result in future complications. These com-

plications are unpredictable and can arise even after the appropriate

use of barbed suture.

Conclusion: Proper handling of barbed suture should be further

evaluated in order to avoid the aforementioned complications.

P-1101

Ventral hernia repair outcomes predicted by a 5-item

modified frailty index using NSQIP variables

Balla F, Yheulon C, Stetler J, Patel A, Lin E, Davis SEmory University Hospital

Introduction: Frailty is defined as a decrease in physiologic reserve

giving rise to vulnerability that is separate from the normal aging

process. Previous studies have validated an 11-item modified frailty

index (mFI) using NSQIP variables to predict outcomes for surgical

patients. Newer studies have condensed this to a 5-item mFI; how-

ever, this has not been validated for use to predict outcomes in ventral

hernia surgery. The aim of this study is to validate the 5-item mFI in

ventral hernia patients as well as determine outcomes and the relative

impact of each frailty variable.

Methods: The NSQIP database was queried from 2011 to 2016 for

patients undergoing ventral hernia repair. Spearman’s rho correlation

was used to determine the degree of correlation between 11-item and

5-item mFI raw frailty scores. Chi squared testing was used to

determine odds ratios (95% CI) for accumulating frailty variables in

both indices with regard to complications vs a baseline of zero

variables present on the 11-item scale. Complications were defined by

the Clavien-Dindo (CD) classification. Univariate and multivariate

analyses were performed on each frailty variable to determine their

relative weighted impacts on outcomes.

Results: 97,905 patients (99.45%) had complete data using the 5-item

mFI. Only 11,549 patients (11.73%) had complete data using the

11-item mFI. There was no difference between groups with regard to

the 5 mutually shared frailty variables, BMI, emergent vs non-

emergent procedures, operative time, or laparoscopic approach. For

each accumulating variable in both indices, the 5-item mFI predicts

incidence of any complications, major complications, and discharge

not to home similarly to the 11-item mFI. The most significantly

weighted variable for complications and discharge not to home is

functional status.

Conclusion: A 5-item mFI accurately predicts outcomes similar to

the validated 11-item mFI and captures more patients for analysis.

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S69 Hernia (2019) 23 (Suppl 1):S50–S100

P-1102

Outcomes of ventral hernia repair in the obese

and morbidly obese: a single institution NSQIP review

Gleason F, Feng K, Baker S, Washburn P, Perkins C,

Richman J, Morris M, Parmar AUniversity of Alabama at Birmingham

Introduction: Post-operative outcomes of ventral hernia repairs

(VHR) in obese and morbidly obese patients are poorly defined. To

identify the association between obesity and postoperative outcomes,

we reviewed our experience in this patient population. We hypothe-

sized that postoperative morbidity and readmission would increase

with increasing body mass index (BMI).

Methods: We identified all patients undergoing elective VHR at our

institution from 2012 to 2017 who were included in the ACS NSQIP.

Hernia specific characteristics were abstracted through chart review.

Hernia width was classified using European Hernia Society width

classification. Surgical site occurrence (SSO) was defined as any

surgical site infection or wound disruption. Descriptive statistics were

calculated, and factors associated with SSO and readmissions in a

bivariate analysis were included in a logistic regression model.

Results: A total of 334 patients underwent elective VHR and had

complete data on hernia characteristics. The mean age was 58.1, 57%

were female, 80.2% were ASA class III, and 14.7% were active

smokers. Average BMI was 31.4. Average hernia length was 8.6 cm

and hernia widths were W1 (34.4%), W2 (44.3%), and W3 (21.3%),

and were similarly distributed across BMI categories. Operative

approach included open (70.0%), laparoscopic (24.6%) and robotic

(5.4%). Mesh was used in 62% of cases. Postoperative SSO occurred

in 5.7% of the cases, and the 30-day readmission rate was 7.2%. In a

logistic regression model adjusting for hernia width, duration of

operation, and patient smoking history, increasing BMI was only

weakly associated with increased SSO (OR 1.081, CI 1.02–1.15) and

unplanned readmission (OR 1.06, CI 1.01–1.12).

Conclusion: We demonstrated that acceptable immediate post-sur-

gical outcomes for elective ventral hernia repair are possible in a

select population of older, obese patients with large hernia defects.

While increasing BMI was associated with increased SSO and read-

missions, these effects were relatively small.

P-1103

Systematic review of robotic-assisted

versus laparoscopic ventral hernia repair

Sarkar A, Mo S, Chan D, Ravindran P, Talbot M, Fisher OSt George Hospital

Background: Ventral hernia repair is among the most commonly

performed general surgical operation. Minimally invasive surgery

through laparoscopic repair has become popular over the last decade.

Robotic-assisted repair is gaining traction with articulated move-

ments, making intra-corporeal defect closure easier. This systematic

review evaluates the current evidence of robotic-assisted ventral

hernia repair (RVHR) versus laparoscopic technique of ventral hernia

repair (LVHR).

Methods: A literature search was conducted using PubMed, Medline,

EMBASE and Cochrane Library databases. Comparative studies

adopting robotic-assisted versus laparoscopic technique for ventral

hernia repair; with C 3 patients; in English language were included.

A predetermined set of data comprising demographic, operative

details, morbidity and mortality outcomes were collected. The review

was conducted in accordance with the PRISMA Statement.

Results: Nine eligible studies, comprising of 1523 patients (889

LVHR; 634 RVHR) were included. Weighted mean age was

53.6 years (LVHR) vs 55.5 years (RVHR) and 55.9% (LVHR) vs

57.8% (RVHR) were female patients. Weight mean BMI (32.8 vs

32.3) and ASA (2.3 vs 2.4) were also similar between LVHR and

RVHR. Weighted mean operation time was shorter in the LVHR

(92.4 min, range 65–121 min) compared to the RVHR group

(134.7 min, range 107–245 min). The conversion to open surgery was

2.7% (LVHR) vs 0.95% (RVHR). Hernia recurrence rates were 4.7%

(LVHR) vs 5.3% (RVHR). Two deaths were reported in the LVHR

patients.

Conclusion: Both robotic-assisted and laparoscopic techniques result

in similar hernia recurrence rates, with longer operation times but

lower conversions to open surgery in the RVHR group. Randomized

controlled trials are required to further assess this area.

P-1106

Fatty inguinal hernia (sacless inguinal hernia)

Aldohayan AKing Saud University Hospital

Background: Fatty Inguinal Hernia [FIH] is inguinal defect filled

with extraperitoneal fat and no sac. Laparoscopic repair of inguinal

hernia requires the presence of a SAC, either direct or indirect

inguinal hernia. Many surgeons aborted the laparoscopic surgery in

absence of the sac. Preoperative examination is important to diagnose

the FIH.

Aim: In presence of suspicion of FIH, laparoscopic examination of

deep inguinal & Hesselbach’s triangle is necessary to diagnose and

manage.

Materials and methods of FIH: The study started from January 2017

till June 2018. All the patients were either examined clinically or by

ultrasound of the groan.

Results: There were 50 patients who were diagnosed inguinal hernia,

8 fatty indirect inguinal hernias and 3 fatty direct inguinal hernias are

encountered.

Conclusion: For a long time, patients who had FIH were managed

improperly, here by we illuminate the case of FIH which surgeon can

miss if were not aware of FIH.

P-1107

Abdominoperineal resection: does closure technique

matter?

Patel P, Ly J, Mak J, Foster LWaikato Hospital

Perineal hernia following abdominoperineal resection.

Aims: To identify the local perineal hernia rate following

abdominoperineal resection (APR) and make comparisons of these

rates between different wound closure techniques.

Methods: Retrospective analysis was carried out on all patients who

underwent an APR (based on ICD-10 coding) at Waikato Hospital

between January 2005 and March 2016. Baseline characteristics were

collected. Patients were grouped based on technique of perineal

wound closure—Simple Suture alone (SSC), Simple Suture with

Vacuum Assistance (SSC ? VAC), Mesh Assisted (MAC) and Ver-

tical Rectus Abdominus Muscle flap (VRAM). Perineal hernia events

documented for each group.

Results: 97 patients were identified and 80 were included in the study

(17 exclusions) This included: SSC 50 (62%), 13 SSC ? VAC (16%),

11 MAC (14%) and 6 VRAM (8%). Perineal hernia rate was 13% (10/

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Hernia (2019) 23 (Suppl 1):S50–S100 S70

80). This includes 10% (5/50) for SSC, 23% (3/13) for SSC ? VAC,

33% (2/6) for VRAM and none for MAC.

Conclusion: Perineal hernia rates were lowest for MAC compared to

any other group. We believe this is related to a relatively smaller

pelvic floor defect and a tension free closure with the use of mesh.

This may similarly be the case when the perineal defect is closed with

SCC, as occurs in selected cases. The rates were highest with VRAM

closure.

P-1108

Minimum incisional hernioplasty assisted

with laparoscope for ambulatory inguinal hernia

surgery

Imazu H, Imazu YImazu Surgical Clinic

Introduction: I perform a Minimum incisional hernioplasty (MIH)

operation to use a laparoscope with local or epidural anesthesia for an

ambulatory groin hernia operation from 2012. This method is

transinguinal preperitoneal hernioplasty using conventional mesh

repair and laparoscope, it has the following some merits.1, shortening

of the wound, 2. It is more exact than the naked eye, because of

expansion.3.post operative pain is slight. 4. Can go home in a short

time.

Method: I diagnosed type of the hernia by ultrasonography before an

operation and decided an operation method. I perform the transin-

guinal preperitoneal hernioplasty from 1.5 to 2 cm length wound.

Until the handling of hernia sac, I used a magnifying glass (4.5 times

expansion). After this processing, I detached as much as possible

between peritoneum and preperitoneal fat tissue layer from an inci-

sional route using 3 mm diameter laparoscope. After detachment, I

measure a detachment range and insert mesh of size as big as pos-

sible. After that, I insert it in prepetitoneal fat tissue layer, and

unfolded the mesh enough under using laparoscope.

Result: I was operated on to 2255 patients 2338 lesions). Their sex

ratio were 9:1 (males: females), with mean age of 57.2 years (range

18–91). The type of hernia was indirect hernia 1741 lesions, direct

hernia 546 lesions and femoral hernia 16 lesions and combine 35

lesions. All cases average operation time were 57 min (with in

bilateral) and mean wound length was 1.66 cm. All cases came home

on same day (mean postoperative time was 37 min) and no severe

complications.

Conclusions: There was not the case that a day surgery was not

possible. The severe complications are not seen after operation, and

the inguinal hernia day surgery is basically possible in all cases by

MIH.

P-1109

Laparoscopic and percutaneous short stitch technique

repair for ventral hernia (a novel technique)

Aldohayan A, AlBalawi M, Bassas R, Alaqel MKing Saud University Hospital

Background: Ventral hernia repair (VHR) is a common procedure.

Despite the frequency of VHR, the optimum repair method has not

been established yet. The aim of this study is to analyze outcomes of

VHR using a combined open (small bite short stitch technique

(SBSST)) and laparoscopic technique.

Method: A retrospective review was conducted for 46 patients who

received a combined laparoscopic and open ventral hernia repair at

the medical city of King Saud university in Riyadh, Saudi Arabia.

Main outcome measures included postoperative complications and

recurrence.

Surgical technique: Mesh size is determined by adding 5 cm longer

than hernia defect size. The mesh is mounted with five sutures to the

edges and center of the mesh number as per the principles set by the

author of patent number US92049SSB.After ports are established and

reduction of hernia sac and content is carried out, small incision is

made over the neck of sac where the sac is incised with sac excision,

the mesh is introduced through the defect of the wound in aseptic

technique which then followed by primary repaired using (SBSST).

The sutures are retrieved through the abdominal wall and mesh is

tacked to the abdominal wall using capture. Transfacial suture

through abdominal wall keeps the mesh in place.

Results: The study started from May 2016 to May 2018, there are 46

patients who underwent ventral hernia repair using this technique

were included. Majority of patients were female (N = 28). The mean

age and body mass index (BMI) were 52.2 years and 32.36 (kg/m2)

respectively. The mean defect size was 33.9 cm2. Postoperative

complications included 2 seroma (4.3%) occurrences, 1 hematoma

(2.1%) and 1 superficial infection (2.1%). At a mean follow up of

17.1 months (range 6–28), there was no evidence of hernia recurrence

or chronic pain.

Conclusion: We demonstrate.

P-1110

Laparoscopic inguinal hernia repair using poly-4-

hyroxybutyrate (P4HB) mesh

Aldohayan A, Albalawi M, AlAqel M, Bassas RKing Saud University Hospital

Background: Inguinal hernia repair is one of the most common

surgical procedures performed by a general surgeon. The use of a

prosthetic implant is usually necessary for successful repair. How-

ever, widely used non-absorbable synthetic meshes have been

associated with recurrence and complications related to significant

shrinkage and foreign body implantation. The non-absorbable prolene

mesh is standard mesh used in laparoscopic repair of inguinal hernia.

The prolene mesh shrunken in the first few months, it may reach to

30% of its original size. Most of the recurrences of laparoscopic repair

of inguinal hernia occurred in the first post-operative year. On the

other hand, phasix mesh (P4HB) start to be absorbed after 1 year. In

the presence of that information we advocate the usage of phasix

mesh (P4HB) in laparoscopic repair of inguinal hernia.

Method: A retrospective review of patients undergoing laparoscopic

inguinal hernia repair with P4HB by one surgeon as day case surgery

were performed. The procedure carried out using 3 ports size 5 mm.

P4HB (PhasixTM) Mesh (15 9 15) has being introduced and spread

over to cover inguinal and femoral area. The mesh is fixed to pubic

bone and anterior abdominal wall by capture trackers. The incised

peritoneum is tacked to the other edge of the peritoneum. The main

outcome measures were hernia recurrence and post-operative com-

plications. Recurrence rates were determined either by physical

examination or via phone follow-up.

Result: The study started from 16 November 2010 to August 2018,

there are 15 patients who underwent LIHR with P4HB were included.

The median patient age was 53.2 years and the median body index

(BMI) was 26.6 kg/m2. There were no mortality, hernia recurrence,

seroma or surgical site infections reported. The median follow-up

period was 13.3 months.

Conclusion: LIHR with P4HB have yielded promising results in term

of patient outcomes, notably the absence of hernia recurrence.

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S71 Hernia (2019) 23 (Suppl 1):S50–S100

P-1111

The use of poly-4-hydroxybutyric acid (P4HB) mesh

in laparoscopic ventral hernia repair (LVHR)

Aldohayan A, Albalawi M, Bassas R, Alaqel MKing Saud University Hospital

Background: Ventral hernia repairs (VHR) are considered to be some

of the most commonly practiced surgical procedures worldwide.

Traditionally, non-absorbable synthetic meshes were used in VHR,

which have been tied to a variety of adverse outcomes such as

recurrence, chronic pain and complications resulting from foreign

body implantation and associated shrinkage. Subsequent advances in

medical devices saw the development of absorbable poly-4-hyroxy-

butyrate (P4HB) meshes such as the Phasix ST Mesh. However,

studies on the viability and potential of this new type of mesh have

been scant. In this study, we report our initial evaluation of the use of

P4HB Phasix ST Mesh in patients undergoing LVHR.

Method: We conducted a retrospective review of all patients under-

went LVHR by one surgeon at Medical city of King Saud University

in Riyadh, Saudi Arabia. Main out comes measures included hernia

recurrence and post-operative complications.

Results: The study is done in Medical City of King Saud University

from November 2016 TO June 2018, there are 17 who underwent

LVHR with P4HB (Phasix ST) were included. The median patient age

was 60.7 years. The median body index (BMI) was 33.3 kg/m2. Post-

operative complications included 1 seroma, 1 early discomfort, 1

chronic pain ([ 3 months) and 1 conversion to open repair due to

huge loss of abdominal domain. There were no mortality, hernia

recurrence, and surgical site infection. The median duration of follow

up was 8 months.

Conclusion: This paper is demonstrating that LVHR with P4HB

(Phasix ST) Mesh had promising early outcomes. However, larger

cohorts of patients as well as longer follow-up durations are required

to corroborate our findings and allow further, more robust analyses.

P-1113

Short-term outcomes for Onlay and Sublay mesh

placement in the management of primary umbilical

hernias: preliminary report of a prospective

randomized trial

Kumaira Fonseca M, Tarso L, Gus J, Pedroso J, Oliveira H,

Cunha C, Cavazzola LHospital Materno-Infantil Presidente Vargas

Introduction: Current evidence supports prosthetic mesh reinforce-

ment to improve long-term results in the surgical management of

primary umbilical hernias. The anatomic position of mesh placement

has several implications on the technical complexity of tissue dis-

section, operative time, incidence of local wound complications,

postoperative pain and recurrence; however, its ideal location is not

yet established. This interim report compares early outcomes fol-

lowing onlay versus sublay mesh placement in elective primary open

umbilical hernia repairs.

Methods: Prospective randomized double-blind study conducted on

female patients diagnosed with primary umbilical hernias (defect size

range 0.5–6.5 cm) and admitted to a secondary hospital in a residency

training program setting. Between October 2017 and August 2018, 25

subjects representing 30% of the estimated targeted sample size were

randomly assigned to either onlay or sublay mesh repair group. The

operative time, early surgical site complications, postoperative pain

and short-term recurrence were reported.

Results: No statistically significant differences were observed

between groups regarding patients’ demographics, comorbidities or

defect size. The median operative time was significantly shorter in the

sublay group (42 vs 65 min, p\ 0001). Surgical site occurrences and

pain severity index on the 30th postoperative day were greater in the

onlay group with no statistical significance (33 vs 20%, p = 0.65; 2.38

vs 1.67, p = 0.4), none requiring surgical reintervention. No recur-

rences were reported after a median follow-up of 7.6 months

(IQR = 1.3–11).

Conclusions: The preliminary data presented herein suggests both

techniques are safe, efficient and associated with low complication

rates. Though considered technically more challenging, sublay repair

group was related to shorter operative times, which suggests the

feasibility of this procedure in a surgical residency program. Further

cases from this ongoing study and completion of long term follow-up

is expected to assess the effect of different mesh fixation techniques in

a larger sample size.

P-1114

The use of narrow mesh for the repair of inguinal

hernia

Nicolo E, Tuveri MJefferson Regional Medical Center

The use of Narrow Mesh for the repair of inguinal hernia.

We retrospectively analysed 185 consecutive patients with pri-

mary and recurrent inguinal hernia treated with the Narrow Mesh

(NM), a new shaped alloplastic mesh. Parameters such as hernia type,

operation time, type of anaesthesia, complications, hospital stay and

recurrence were evaluated. Two hundred three procedures were per-

formed on 185 adult male patients. Inguinal hernias were unilateral in

167 patients, bilateral in 18 patients. Median age was 47 (range

18–77). According to Nyhus classification, there were 35 (17%)

Nyhus type I hernias, 44 (22%) Nyhus type II hernias, 54 (27%) with

Nyhus type IIIa hernias, 39 (19%) with Nyhus type IIIb hernias, and

31 (15%) with Nyhus type IV hernias. Epidural anaesthesia was used

in 61 (30%) procedures, while local anaesthesia was used in 142

(70%). Ileo-inguinal nerve excision occurred in 37 (18%) patients. No

intra-operative complications were registered. Median operation time

was 38 (range 21–86) min. Median hospital stay was 13 (range 6–36)

h. After a median follow-up of 61 months (range 48–77), there were

not recurrences. Chronic inguinal pain at 1 year occurred in 1 patient

(0.5%).

We conclude that the NM repair is a safe and effective repair with

a low rate of postoperative complications, low recurrence rate and a

very low incidence of chronic inguinal pain.

P-1115

Optimizing nomenclature in endoscopic hernia repair:

how to achieve ‘‘Critical View’’ in TAPP and TEP

Claus C, Furtado M, Malcher F, Cavazzola LJacques Perissat Institute/Positivo University

Introduction: Interest in endoscopic repair of inguinal hernia has

recently increased among surgeons. However, posterior inguinal

anatomy is not usual for general surgeons and there’s a lack of

standardization and reproducibility of surgical repairs. These are

factors that preclude dissemination of endoscopic approach. Recently

Feliz and Daez described 10 fundamental steps to the success of

laparoscopic repair.

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Hernia (2019) 23 (Suppl 1):S50–S100 S72

Objectives: facilitate understanding of surgical steps and create a

form of universal communication between surgeons.

Methods/Results: Standard dissection and anatomical recognition of

posterior inguinal anatomy in 3 zones of dissection and 5 triangles, as

follows. Zone 1: lateral area. Main anatomical references: anterior

superior iliac spine, iliopsoas muscle, iliopubic tract. Aim of dissec-

tion: reach the ilio-psoas muscle; keep fat tissue in contact with the

pelvic wall; avoid manipulation of nerves; avoid traumatic fixation of

mesh. Zone 2: medial area. Main anatomical references: rectus

abdominis, bladder and pubic bone. Aim of dissection: visualize

entire pubic bone til the symphysis; reduce preperitoneal fat of

transversalis fascia (direct hernia); dissect the bladder at least 2 cm

below the pubic bone. Zone 3: central area. Main anatomical refer-

ences: spermatic vessels and vas deferens (in woman—round

ligament); external iliac vessels; inferior epigastric vessels; deep

inguinal ring. Aim of dissection: reduce the peritoneal sac of the deep

inguinal ring (indirect hernia) to at least the level of vas deferents

crossing external iliac vein; reduce tissue anteriorly to iliac vein and

visualize it (femoral hernia); explore the deep ring and reduce lipoma

if present. At the end of dissection, the surgeon must recognize the

figure of an inverted Y (corresponding to the inferior epigastric

vessels, spermatic vessels and vas deferens) and 5 triangles (disaster,

pain, indirect, direct, femoral).

Conclusion: This is a very simple way to leave standardize and easily

disseminate posterior inguinal anatomy and endoscopic hernia

surgery.

P-1117

Endoscopic totally extraperitoneal approach (TEA)

for primary ventral hernia repair

Li B, Qin C, Miao J, Li Y, Gong DAffiliated Hexian Memorial Hospital of Southern Medical University

Background: Numerous surgical alternatives have emerged for the

treatment of ventral hernia. Following the same principle of TEP

technique for inguinal hernia. We developed a novel approach to treat

primary midline ventral hernia——endoscopic totally extraperitoneal

approach (TEA).

Methods: During September 2017 and June 2018, fourteen consec-

utive cases of primary midline ventral hernias were repaired using the

TEA procedure. During the procedure, we built up pneumoperi-

toneum in the Retzius space directly through a 12 mm Trocar which

was located on the suprapubic region. After 2 working ports were

placed, we dissected this extraperitoneal space cranially, hernia sacs

will be reduced or transected during the dissection. After an ample

extraperitoneal space was built cephalad, a large mesh could be

placed in the epigastric preperitoneal position to repair the defect.

Results: All operations were successful without open conversion. The

mean operation time was 100 min (75–135 min). Postoperative pain

was mild and the mean VAS was 2.0 on first postoperative day. The

average postoperative stay in hospital was 2.1 days (1–3 days). One

case experienced postoperative seroma but without adverse effect on

the final outcome and no recurrences during the follow-up period of

3–11 months.

Conclusions: TEA procedure is safe, feasible and minimally invasive

requiring no specific device. It is in compliance with the anatomical

and physiological natures of the abdominal wall, which could reduce

trauma and postoperative complications dramatically. Besides there is

no need for expensive anti-adhesion mesh and fixation tacker, which

make it more cost effective. TEA is a good technique for the surgical

treatment of primary ventral hernia.

P-1128

Massive abdominal hernia after sternal infection

Schlosser K, Maloney S, Augenstein V, Heniford BCarolinas Medical Center

Introduction: The development of subxiphoid hernias is a known

complication after cardiac surgery. Here we discuss the repair of a

massive abdominal and chest wall hernia after sternal infection with

debridement.

Case report: A 74-year-old male physician with history of hyper-

tension, coronary artery disease, and remote inguinal hernia repair

presented for hernia repair. The patient had a history of Adult Onset

Still’s Disease with associated myocarditis requiring emergent coro-

nary artery bypass with aortic and mitral valve replacement.

Postoperative sternal infection and dehiscence secondary to Candida

required multiple sternal debridements with subsequent herniation of

abdominal contents into the chest and extending subcutaneously to

the sternal notch. He had a previously failed hernia repair and a

cholecystotomy tube due to prior cholecystitis. On exam, he had a flat

abdomen with a healed midline scar and obvious subcutaneous

intestine extending well up his chest wall. CT demonstrated an

abdominal and chest wall hernia with viscera extending from

umbilicus to clavicles. Surgical repair was performed with Plastic

Surgery. Following a laparotomy, lysis of adhesions, excision of prior

synthetic mesh, and cholecystectomy, a preperitoneal plane was

developed. The peritoneum was closed over the viscera, and a 30 by

35 cm synthetic mesh was placed in the preperitoneal space. The

mesh was fixated to the inferior costal margin with care to protect the

pericardium and secured with transfascial sutures in the lateral and

inferior abdomen. Bilateral subcutaneous advancement flaps and

posterior rectus release enabled primary closure of abdominal fascia

over the mesh. A layered subcutaneous and cutaneous closure was

performed. Postoperative course was notable only for a medically

managed episode of atrial fibrillation and a small seroma which

resolved spontaneously.

Discussion: Cardiothoracic intervention can lead to challenging

subxiphoid hernias. Here we describe successful repair of a massive

abdominal and chest wall hernia after partial sternotomy.

P-1129

The impact of gender on ventral hernia repair (VHR)

outcomes

Schlosser K, Maloney S, Prasad T, Colavita P, Augenstein

V, Heniford BCarolinas Medical Center

Aims: The relationship of patient gender to surgical outcomes has

been rarely studied, poorly understood and often not considered. This

study evaluates the impact of gender on outcomes after VHR.

Methods: Demographics and outcomes were examined for all Inter-

national Hernia Mesh Registry VHRs (2007–2017), including

laparoscopic (LVHR) and open VHR (OVHR). Ideal quality of life

(QOL) was defined as no pain, movement limitation, or mesh

sensation.

Results: 1850 patients underwent VHR in the study period (41.2%

LVHR, 58.8% OVHR). 44.1% of VHR patients were female. LVHR

was performed in 48.8% of females and 35.2% of males (p\ 0.0001).

Females patients had higher BMI (32.0 ± 8.0 vs. 30.7 ± 5.7 kg/m2,

p\ 0.009), larger hernias (51.6 ± 76.4 vs. 38.9 ± 96.6 cm2), and

longer hospital stay (3.2 ± 4.3 vs. 2.1 ± 2.9 days). Females were

more likely to have a recurrent hernia (20.7 vs. 13.8%, p\ 0.0001),

be on immunosuppression (3.9 vs. 1.1%, p = 0.006), and have

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S73 Hernia (2019) 23 (Suppl 1):S50–S100

preoperative symptoms (74.5 vs. 52.5%, p\ 0.0001). Preoperative

non-ideal QOL was consistently associated with non-ideal QOL at 1,

6, 12, and 24 months postoperatively (OR 2.5, CI 1.54–4.07; OR

1.91, CI 1.40–2.62; OR 4.03, CI 2.66–3.11; OR 3.14, CI 2.13–4.62;

OR 4.72, CI 3.05–7.29, respectively). LVHR was associated with

non-ideal QOL at 1, 6, and 12 months (OR 1.81, CI 1.33–2.46; OR

1.51 CI 1.05–2.17; OR 1.56, CI 1.12–2.2, respectively). Following

surgery, females had no difference in surgeon-confirmed recurrence

or complications (infection, seroma, reoperation). More females had

non-ideal QOL at 1, 6, 12, and 24 months after surgery (53.8 vs.

41.0%, 37.2 vs. 28.0%, 35.6 vs. 22.4%, 37.6 vs. 22.7%, p\ 0.0002

all values). Multivariate analysis controlled for potential confounding

factors (gender, operative approach, BMI, defect area, number of

previous recurrent hernias, presence of multiple defects, and pre-op

non-ideal QOL). Females had non-ideal QOL at 1 month and

12 months (OR 1.76, CI 1.29–2.42; OR 1.46, CI 1.04–2.06,

respectively).

Conclusion: Females undergoing VHR experience more non-ideal

postoperative QOL. The etiology of these differences is poorly

understood and warrants further investigation.

P-1131

Characteristics of the clinical trials conducted

in the field of abdominal herniology

Ahmed F, Shahzad N, Krpata DDow Medical College

Background: Clinical trials are often heterogeneous in their

methodology, which can compromise the interpretability and com-

parability of their results. The methodological quality of trials in

abdominal herniology has not been assessed previously.

Objective: The aim of the study was to identify the strengths and

weaknesses of the methodology used in abdominal hernia clinical

trials.

Methods: Clinicatrials.gov was searched using the term ‘hernia’, and

the results were screened to include trials studying abdominal (ventral

or inguinal) hernias from October 2007 to October 2016. The

Aggregate Analysis of ClincalTrials.gov (AACT) dataset was loaded

onto a relational database management system (Post-

greSQL) to extract the data of the screened trials. SPSS v.23 was

used for all descriptive analysis.

Results: Out of the 985 interventional trials yielded by our search

strategy, 315 met the inclusion criteria. Inguinal hernias were more

frequently studied than ventral hernias (53.7% and 44.4% respec-

tively). About half (45%) of the trials were completed, but only 17.6%

of the completed studies had reported their results on clinicaltrials.-

gov. Although randomization was common (87.3%), less than half

(45%) of the trials were double-blinded. ‘Procedure’ was the preva-

lent intervention (45%), and pain was the most common primary

outcome measure (42%). Around 72% of the trials specified their

primary purpose as ‘treatment’. A large majority (80%) had a parallel

group design. Majority (62.9%) of the studies were single center

studies. Around 59% of the studies had an enrollment size between 1

and 100. Of the 239 trials that listed primary investigators, 87.4%

were led by males.

Conclusion: Our study identifies lack of double-blinding, and lack of

multicenter studies as the primary shortcomings in abdominal

herniology clinical trials. Pain, a subjective measure, is often used as

the primary outcome. The staggering gender disparity amongst pri-

mary investigators is concerning and should be inquired further.

P-1133

Epigastric hernia has been forgotten?

Sanchez-Montes IGeneral Hospital Tlahuac

Introduction: The epigastric hernia coined by Leveille in 1812.

These include hernias through the upper part of the linea Alba, but

exclude umbilical hernia. The etiology of the epigastric hernia (EH) is

approximately 10 paired neurovascular bundles perforate this fascia

anteroposteriorly, creating small orifices through which preperitoneal

fat can insinuate itself, starting incipient hernias that grow with age

and increased weight. These anatomical characteristics explain the

main reason why these hernias are multiple in 20% of patients. EH is

found in 5–10% of autopsies, and from other sources of reports,

according to surgically treatment hernias are present among 0.5–5%.

Purpose: The aim this presentation is to remember that the EH exists,

and can be repaired with a tension free repair technique.

Materials and methods: From January 2000 until August 2018, my

professional experience I performed 48 operations in the same

number of patients with EH, out of them 45 patients with primary

hernias, 3 with a first recurrence. Mean age was 52 years (23 to 81).

There were 22 males, and women 26. The mean of body mass index

(BMI) was 32.19 kg/m2. Associated with umbilical hernia in 44%

operated at the same time. The size of the defect varied from 1 cm to

5 cm intraoperatively.

The Surgical technique was mesh small plug when the size

defect\ 2.5 cm and preperitoneal mesh repair when the defect

was[ 2.6 cm. All our patients we follow up 1, 3, 6 months and every

year.

Result: There were minor complications, three patients developed

seroma, none of them presented infection and recurrent hernia.

Conclusion: Those techniques simplify the repair and the advantage

of producing minimal postoperative pain, there was not a recurrence.

P-1134

Comparison of various inguinal hernia repairs

in the community setting

McCoy K, Madris B, Symons WStamford Hospital

Surgery continues to adapt and evolve with the primary goal of

improving outcomes through use of increasingly less invasive pro-

cedures. The superiority of laparoscopic compared to open surgery for

outpatient procedures, such as the inguinal hernia repair, has been

well documented over the past several years. Laparoscopy has a

prolonged learning curve however robotic surgery may expedite this

learning curves with its 3D visualization and articulating instrumen-

tation. Our study looks to prove that there is a potential future role for

robotic surgery in the outpatient setting.

In this study, we performed a retrospective analysis of 90 patients

who underwent either a laparoscopic or robotic-assisted laparoscopic

or open inguinal hernia repair at Stamford Hospital, from July 2017 to

August 2018 with same day discharge. The following characteristics

were analyzed for both subsets of patients: gender, BMI, type of

repair, operative time, recovery room time, immediate post-operative

pain, and post-operative pain 3 h after surgery.

Our study demonstrated longer average operative time for patients

undergoing robotic hernia repair (79.125 min) compared to laparo-

scopic repair (50.5 min) and to open repair (64 min), which was

statistically significant (p value =\ 0.05). Patients who underwent

robotic inguinal hernia repair had a lower average numerical pain

score in the post-operative period and received less post-operative

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Hernia (2019) 23 (Suppl 1):S50–S100 S74

narcotics compared to the laparoscopic and the open cases. There was

a statistically significant difference in post-operative narcotic usage

between the open and robotic groups.

This study highlights several possible advantages of robotic

inguinal hernia repair, including lower post-operative pain scores and

less narcotic usage required in the post-operative period. These trends

needs to be further studied to determine their overall significance in

the field of hernia surgery.

P-1135

A study of mesh compliance: implications for proper

splinting for fascial repair in abdominal wall

reconstruction

Langstein H, Ferzoco S, Pacella S, Greenhalgh E, Farrell BUniversity of Rochester School of Medicine and Dentistry

Introduction: Mesh reinforcement of ventral hernias has been shown

to reduce recurrence rates. The precise mechanism whereby synthetic

or biologic meshes reduce recurrence is not fully known. It appears

that mesh placement may offload or splint the primary fascial repair

until it becomes sufficiently strong enough to support the normal

pressures of the abdominal wall. Once this strength is achieved, the

ideal mesh provides ongoing support without altering the native

compliance of the abdominal wall. Therefore, the mesh needs to have

low compliance initially and should then become somewhat more

pliable and compliant long term. Native compliance of the human

abdominal wall ranges between 11 and 32%. This study was per-

formed to test the initial compliance of two mesh systems—

reinforced biologic mesh (OviTex, TelaBio) and resorbable

monofilament mesh (Phasix, Bard) in order to measure their suit-

ability to offload fascial repairs.

Materials and methods: OviTex Core (4 layers), OviTex 1S (6

layers), OviTex 2S (8 layers) and Phasix were tested for uniaxial

tensile strength per ASTM D638 using the Type IV test configuration.

Uniaxial compliance was determined as a post-test calculation.

Results: The results of the testing and post-test mean compliance

calculations are presented in below:

Compliance STD Sample Size

OviTex 14.2% 4.56% 36

OviTex 1S 11.9% 3.60% 36

OviTex 2S 10.9% 2.82% 36

Phasix 52.5% 7.63% 5

The measured difference in compliance is well illustrated using

video.

Conclusions: This study evaluated the compliance or ‘‘elasticity’’ of

two types of meshes used in abdominal wall repair and found OviTex

meshes to be significantly less compliant than Phasix. OviTex meshes

do not stretch to the degree that Phasix does, and appear to be better

suited to offload or splint a primary fascial repair,

P-1136

Repair of giant inguinal hernia

Kircher C, Abidi H, Shebrain SBronson Methodist Hospital

A 76-year old gentleman presented with a giant right inguinal hernia.

Over last 20-years, the hernia has progressively increased in size and

adversely affecting his quality of life (QL) leading to; loss of the

normal micturition mechanism requiring self-catheterization, back

pain and postural change and perturbation to his stance with shifting

the center of body mass due to progressively increasing weight of the

scrotum, and mechanically-limited ambulation. On examination

(Figure 1a), he has scaphoid abdomen (most bowel has migrated to

scrotum) with a giant, non-reducible right inguinoscrotal hernia,

extending down to the level of his knees. He was hesitant to undergo

surgery. However, he was hospitalized for a small bowel obstruction

within his hernia as seen in a CT scan (Figure 1b) and was managed

non-operatively. After a pre-operative medical optimization, an

elective open repair was performed. An inguinal incision was utilized.

Hernia sac and spermatic cord structures were identified. Cord

structures were protected. While in Trendelenburg position, the hernia

sac contents (the majority of the small bowel, appendix, cecum,

ascending and transverse colon (Figure 2a–d) were sequentially

reduced to the abdomen. A partial omentectomy was performed.

During the repair, the peak airway pressure was monitored. The

stump of the sac was closed using non-absorbable suture (NAS). A

tension-free prolene mesh repair was performed. The mesh was

sutured to the inguinal ligament, the conjoint tendon using interrupted

0 NAS. A new internal ring was recreated. Layers closure [(the

external oblique aponeurosis (2-0 Vicryl), Scarpa’s fascia (3-0 Vicryl)

and the skin (stapler)] was performed. A suction drain was placed

within the right scrotum. The patient was extubated. He was dis-

charged home on POD#3. He developed early satiety that improved

over 2 weeks. At 5-months follow-up, the patient is doing well, with

pain resolved, tolerating general diet and better QL (Figure-3A.

P-1138

Results of robotic ventral hernia repair with phasix

bioabsorbable mesh: a fellowship council accredited

training fellowship’s experience Stefanie Haynes Do,

Frederick Sabido Md, Facs, Richmond University

Medical Center, Staten Island, New York

Haynes S, Sabido FRichmond University Medical Center

Introduction: The use of the robotic platform for ventral hernia

repair has been proven to result in less surgical site infections and

surgical site occurrences in multiple studies. We report our experience

which further promotes the impact that robotics has had on reducing

recurrence rates and post-operative complications specifically when

fully resorbable mesh is utilized.

Methods: The American Hernia Society Quality Collaborative data-

base was used to identify patients undergoing robotic ventral hernia

repair from March 2017–August 2018 by a program director and

fellow. The primary outcome measured was recurrence at 4 weeks,

20 weeks and 17 months. Secondary outcomes included SSIs, SSOs,

readmission and chronic pain. Patient demographics and intraopera-

tive data were collected. All repairs utilized the Intuitive daVinci Si

robotic platform. Primary closure of the hernia defect was completed

with absorbable unidirectional barbed suture and uniquely a fully

123

S75 Hernia (2019) 23 (Suppl 1):S50–S100

resorbable Phasix monofilament mesh was positioned as an

intraperitoneal onlay (IPOM).

Results: A total of 48 patients undergoing ventral hernia repair were

examined- 22 female and 26 male. The mean age was 54 and BMI

33.8. The types of ventral hernias repaired were umbilical (40%),

incisional (33%), epigastric (21%), and Spigelian (0.06%). The mean

ASA was 1.9 and operative time was 0–59 min. All patients were

discharged on the same day post operatively. Recurrence at 4 weeks

was 0%, 20 weeks 0% and 17 months 4% (2/48). There were no SSIs,

SSOs, readmissions or mesh infections reported. The average pain

post operatively was moderate and current pain was 0/10 on the pain

scale.

Conclusions: This preliminary data demonstrates that fully resorbable

mesh combined with the benefits of robotic technique for ventral

hernia repair can reduce or eliminate the incidence of recurrence and

post-operative complications which has not been shown to date.

P-1139

Management of incarcerated spighelian hernias

in a tertiary academic center in Brazil

Pivetta L, Barros P, Tastaldi L, Barros R, Fantauzzi M,

Hernani B, Assef J, Altenfelder Silva R, Roll SSanta Casa de Sao Paulo School of Medical Sciences

Introduction: A Spigelian hernia (SH) presenting acutely with pain,

incarceration or strangulation is a rare and challenging clinical sce-

nario. We aim to describe different operative approaches for the

management of SH illustrated by three cases that were managed at the

emergency service (ER) of a tertiary academic center in Sao Paulo,

Brazil.

Methods: (1) 32-year-old male, IVDA and unfortunately in a

homeless situation, presented to the ER with a 2-day history of

abdominal pain and small bowel obstruction. A painful mass could be

palpated at left lower quadrant consistent with an incarcerated SH.

Repair was performed through an open approach with hernia reduc-

tion, defect closure and placement of a medium-weight polypropylene

mesh (MWPP) in preperitoneal position. (2) 64-year old female,

presented to ER with recurrent episodes of right lower quadrant pain.

CT-Scan demonstrated a reducible right SH. Repair was performed

through a laparoscopic transabdominal preperitoneal (TAPP)

approach, with defect closure and placement of MWPP as a sublay.

(3) 72-year old female presented to ER with a 1-day history of left

lower quadrant pain without any palpable mass. A CT Scan demon-

strated a bilateral SH with small bowel incarceration on the left side.

Repair of bilateral SH’s was performed through a laparoscopic

approach with intraperitoneal onlay mesh (IPOM).

Results: There were no intraoperative complications; neither required

bowel resection and recovery of patients was uneventful. Patients

were discharged on postoperative days 2, 1 and 1 respectively. Patient

1 was lost to follow-up. Patients 2 and 3 had no wound or medical

complications and are recurrence-free at the last follow-up available

(3 months and 4-years respectively).

Conclusion: SH can be managed in an acute setting through different

approaches. Surgeons should be aware of the possibility of incar-

cerated SH in patients presenting to ER with abdominal pain and

palpable masses in the.

P-1140

Intra-abdominal malignancy of unknown origin

presenting as a strangulated umbilical hernia: a case

report

Kumaira Fonseca M, Bastos R, Oliveira H, Cunha C,

Rehbein P, Varella M, Crespo AHospital de Pronto Socorro de Porto Alegre

Introduction: Intra-abdominal primary tumours and metastasis have

been reported as rare contents of umbilical hernia sacs. These

malignancies can be misdiagnosed as an incarcerated or strangulated

hernia. The current report describes an intrahernial neoplasm with no

primary sites found presenting as a strangulated umbilical hernia.

Case report: A 65-year old female patient with a history of a pre-

viously reducible umbilical hernia presented to the Emergency

Department (ED) complaining of a painful ulcerative lesion with

purulent discharge and overlying skin necrosis in the periomphalic

region. Abdominal computed tomography revealed a large expansive

mass arising from the mesenteric fat, surrounded by a segment of

ileus and protruding through the umbilicus. No symptomatic or

radiological evidence of bowel ischemia, obstruction or peritonitis

was observed. Surgical exploration of the hernia sac and excision of

the tumorous mass was performed by a midline laparotomy. Exten-

sive histological examination and further immunohistochemical

staining of the specimen revealed epithelioid and fusocellular

malignant cells with abundant atypical mitotic figures, yet failed to

identify the specific primary source of the tumour. The patient was

discharged after an uneventful recovery and declined to proceed

further investigation or treatment. After 4 months, she was readmitted

to the ED with acute bowel ischemia due to tumour progression and

multi-focal dissemination of the disease found intraoperatively,

expiring within 12 h after presentation.

Discussion: Although intrahernial tumours are rarely seen in clinical

practice, an umbilical mass may present as the first manifestation of

undiagnosed malignancy. Longstanding umbilical hernia that sud-

denly become incarcerated or strangulated warrants clinical suspicion

and additional diagnostic evaluation for neoplastic disease.

P-1142

Hernia repair for the underserved: fostering surgical

education and assisting underserved populations

in Brazil

Kawamoto Fujikawa V, Lima Konichi R, Copin Tenorio R,

Sembarski Oliveira E, Fogaca de Barros P, Altenfelder

Silva R, Chen D, Filipi C, Roll SSanta Casa de Sao Paulo School of Medical Sciences

Background: Hernia Help—Hernia Repair for the Underserved

(HRFU) is a non-governmental organization (NGO) that has the

objectives of (1) provide free hernia surgery to underserved popula-

tions, (2) train local surgeons in a competency-based training program

and (3) assist local authorities in creating self-sustaining hernia repair

teams that can provide further care in the community. We aim to

report the outcomes of 3 missions of HRFU in Brazil.

Patients and methods: From September 2014 through August 2018,

four missions took place in the state of Sao Paulo, involving under-

served communities who rely on the medical care provided by the

Brazilian public health system. Local surgeons were invited to par-

ticipate in a series of 3–5 inguinal hernia repairs, directly mentored by

one of the expert HRFU-affiliated volunteer trainers.

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Hernia (2019) 23 (Suppl 1):S50–S100 S76

Results: Four missions were performed in 7 different cities; 236

inguinal hernias were repaired and 52 local surgeons were trained.

Five percent of patients were female. All patients had inguinal hernias

that were more frequently unilateral (94%); 57% were on the right

side. All procedures were performed using the Lichtenstein technique,

with permanent synthetic mesh, 95% (224) were performed under

local anesthesia and there were no intraoperative complications.

There were 14 complications (5.9%): 11 were hematomas, 2 were

surgical site infections and one patient developed chronic groin pain.

No recurrences were detected to the date this abstract was produced.

Eleven surgeons were selected by the organization to serve as trainers

in subsequent missions.

Conclusion: Humanitarian endeavors like HRFU can not only pro-

vide free, high-quality surgical care to underserved populations but

more importantly, are a valuable initiative to educate surgeons in

developing countries to build a sustainable hernia program in their

communities.

Renata Yumi Lima konichi.

P-1143

Bioprosthetic versus synthetic mesh: analysis

of integration in an experimental animal model

Adelman D, Cornwell KMD Anderson Cancer Center

Introduction: Synthetic and bioprosthetic meshes play important

roles in ventral hernia repair. Although sometimes used inter-

changeably, these devices have inherently different properties. We

therefore sought to better understand how these materials interact

with the host environment to optimize surgical techniques and

improve outcomes.

Methods and materials: Synthetic mesh (polypropylene) or bio-

prosthetic mesh (acellular fetal/neonatal bovine dermis, SurgiMend)

was implanted in a novel rat intra-abdominal implant model. Three

variables were modified with each material: (1) tight or loose tissue

apposition, altered by modifying suture placement; (2) abdominal

wall injury, altered by selective abrasion of the peritoneal lining; and

(3) suture material. After 5 weeks, the meshes and abdominal wall

were evaluated grossly and histologically. Analyses focused on the

degree of inflammatory response, neovascularization, and mesh

adherence to surrounding tissues.

Results: Synthetic mesh adhered to the abdominal wall and visceral

organs, regardless of variable, due to a foreign body-mediated

inflammatory reaction. SurgiMend was adherent to the abdominal

wall only in areas of suture placement, which also served as points of

neovascularization. Denuding the peritoneal lining increased Surgi-

Mend to tissue adherence in those areas. Degradable sutures yielded

greater inflammation, increasing the magnitude and distribution of

cells repopulating the matrix, but ultimately did not affect the strength

of the tissue attachment to the abdominal wall.

Conclusions: The inflammatory and wound healing responses with

bioprosthetic mesh seem fundamentally different from synthetic

mesh. Further understanding of these differences may lead to

improved outcomes in adherence and vascularization of the materials,

and ultimately improved efficacy of hernia repair.

P-1144

Effect of suture type on the attachment strength

and assimilation of extracellular matrix biomaterials

in hernia repair

Adelman D, Cornwell KMD Anderson Cancer Center

Introduction: Acellular dermal matrices (ADMs), like synthetic

meshes, are used in ventral hernia repair. We previously demonstrated

that SurgiMend, derived from fetal/neonatal bovine dermis, integrates

through suture approximation and localized tissue injury, acting as

points of adherence and neovascularization. We wondered if altering

the suture material would affect the integration process, hypothesizing

that more rapidly degradable sutures might increase local inflamma-

tion yielding greater neovascularization of the mesh, but at the

expense of lessened tissue adherence.

Materials and methods: SurgiMend was placed intra-peritoneally,

altering suture type (Prolene, PDS, Maxon, Vicryl, Vicryl Rapide),

selective abrasion of the peritoneum (none vs some), and length of

experiment (4 vs 12 weeks). Implants were grossly visualized; half

subjected to mechanical strength/mobility testing against the

abdominal wall, half analyzed histologically.

Results: Attachment strength range was 3 N–15 N for all conditions,

3 N–6 N once the suture degraded (or permanent suture transected).

All were statistically significantly lower than the attachment strength

with tissue abrasion (12.88 N ± 5.93). Inflammation was centered

about the suture material, with inflammatory response highest with

Vicryl and Vicryl Rapide, lowest with Prolene. With increased

inflammation, more cells were counted at the 4 week time point, on

the anterior surface of the implant closest to the abdominal muscle.

This effect diminished, leaving fewer and more evenly distributed

cells with time and once the suture had degraded. With prolene,

regions of the implant were virtually cell free at 4 weeks and

remained low at 12 weeks. In the abrasion condition (pro-

lene ? abraded peritoneum), an even distribution of cells was found

throughout the implant at both time points, in quantities significantly

higher than prolene alone.

Conclusion: Cell repopulation and attachment strength of SurgiMend

are dominated by environmental factors of the surgical procedure.

Suture type and peritoneal abrasion may play important roles in post-

implantation mesh physiology and efficacy of hernia repair.

P-1146

3d T-shaped mesh for linea alba reinforcement: results

in an animal model

Hernani B, Barros P, Tastaldi L, Neto I, Amaral P, Ferreira

F, Silva R, Garcia D, Roll SSanta Casa de Sao Paulo School of Medical Sciences

Introduction: The use of prophylactic mesh as a way to reduce

incisional hernia formation in high-risk populations is gaining

increasing attention. We have hypothesized that in an animal model,

the reinforcement of linea alba with an innovative polypropylene ‘‘3D

T-shaped’’ mesh during laparotomy closure could result in increased

resistance in tensiometric measures.

Methods: A model with New Zealand rabbits was used, and 27 animals

were operated. Following a midline incision, animals were divided into

three groups according to method laparotomy closure: (1) 10 9 3 cm

3D T-shaped medium-weight polypropylene coated mesh; (2) 10 9

3 cm 3D T-shaped medium-weight polypropylene uncoated mesh and

(3) control-closure without mesh reinforcement. In groups 1 and 2,

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S77 Hernia (2019) 23 (Suppl 1):S50–S100

mesh was sutured along the fascial edges. After 4 months, animals were

euthanized, the abdominal wall was resected and exposed to ten-

siometer testings. Additional outcomes included incisional herniation,

visceral adhesions to the mesh and wound complications.

Results: 26 animals survived the experiment and were euthanized.

There was no significant difference between the groups in maximum

tensile strength (p = 0.250) or stretching of the abdominal wall under

maximal tension (p = 0.839). Also, no significant difference in inci-

sional hernia rates between groups was seen (p = 1.0), with a single

incisional hernia seen in the control group and none in the experi-

mental groups. Visceral adhesions to the abdominal wall and mesh

were noted in all cases with mesh reinforcement but in only 55% of

the control group (p = 0.02). The degree of visceral adhesions was

higher in the group with uncoated mesh when compared to the

uncoated mesh (p\ 0.05) and control groups (p\ 0.05). No animals

had wound complications.

Conclusion: In rabbits, the addition of a ‘‘3D-shaped’’ mesh in the

current format as a method to reinforce laparotomy closure has not

resulted in significant differences in tensiometer measures when

compared to simple closure of the abdominal wall.

P-1147

Laparoscopic hiatal hernia repair in 51 patients:

outcome and experience

Yang HBeijing Chaoyang hospital

Background and objectives: Hiatal hernia is a common condition

and quite often associated with symptomatic gastro-esophageal reflux

disease (GERD). The aims of this study were to examine the safety

and efficiency of the laparoscopic hiatal hernia repair (LHHR) with

mesh to reduce the GERD symptomes and hiatal hernia recurrence.

Methods: We retrospectively reviewed LHHR from July 2012 to July

2017. The primary outcome was the efficiency of this procedure, and

this was evaluated by the control of the GERD and hiatal hernia

related symptomes and the recurrence rate of hiatal hernia. The sec-

ondary outcome was the safety of the procedure, and this was

evaluated by the incidence of complications.

Results: A total of 51 patients who underwent LHHR during this

period. The Dor fundoplication was performed at the same time if no

contraindication. The average operation time was 100 ± 19.6 min,

the average blood loss was 28 ± 15.4 ml, and average hospital stay

was 2ds.The GERD related symptoms and hiatal hernia related

symptoms were significantly improved. The patients return to normal

diet within 4 weeks after operation. The follow up was on average

32 months, and no recurrence or mesh related complications

identified.

Conclusions: LHHR with mesh is a safe and efficient procedure, and

is able to reduce the recurrence compare to the suture repair.

P-1148

Patients with systemic reaction to their mesh: real

people with real problems

Towfigh S, Fadaee N, Sharma R, Mazer LBeverly Hills Hernia Center

Purpose: We have noticed an increasing number of patients pre-

senting with systemic reaction to their hernia mesh. We present our

experience in diagnosing and treating this interesting subpopulation

of patients who require mesh removal due to a bonafide reaction to the

mesh product itself.

Methods: All patients who underwent mesh removal for mesh reac-

tion from Aug 2013-Aug 2018, were compared to those with no mesh

reaction, e.g., meshoma, hernia recurrence, infection, etc.

Results: Over 5 years, 112 required mesh removal. Of these, 18

(16%) were for systemic reaction to the mesh product itself. Their

incidence increased annually, from 9% in 2013, to 33% in 2017.

Those with mesh reaction were significantly younger (40 vs 56 years.,

P\ 0.001) and significantly more likely to be female (72% vs 36%,

P = 0.004) than those with no mesh reaction. Common complaints

included rash, swelling, fatigue, joint pain, headache, and exacerba-

tion of underlying chronic illness. Some already had allergies to

multiple pathogens. In some, we performed skin allergy testing for

Type IV hypersensitivity to the mesh.

All patients underwent complete mesh removal. Their pain improved

2 weeks postoperatively (6/10 down to 3/10), similar to those with no

mesh reaction (5/10 down to 3/10, P = NS). Long-term follow-up at

1 year showed resolution of symptoms in 78%.

Conclusions: We present insight into diagnosis and treatment of a

unique but rising population of patients who suffer from a true mesh

reaction. They tend to be younger and female. They present with

symptoms not typically seen post-herniorrhaphy, such as new rash,

swelling, fatigue, joint pain, headache, and exacerbation of their

underlying chronic illness. Allergy testing is in its early stages, but

seems promising. Pain improvement is expected after mesh removal.

Complete mesh removal resolved symptoms in 78% of patients.

P-1149

Treatment of the post-partum abdominal wall

dysfunction

East B, Vitujova M, Radvansky J, Lischke RFN Motol

Background: Post-partum floppy belly is a common issue bothering

many new mothers. With the number of pregnancies, the problem

worsens and combined with rectus diastasis leads to a surgical

reconstruction with a use of a large mesh with a potential loss of

abdominal wall compliance. Medical physiotherapy is able to help

these patients lose weight and strengthen their abdominal wall

including the diastasis with no need of a subsequent surgery.

Methods: From 1.1.2015 to 14.9.2018 62 patients with post-partum

umbilical hernia and rectus diastases were assigned into the Motion

therapy programme we have established at our institution in coop-

eration with the Sportsmed and Rehabilitation dpt. Since the cost

effectiveness analysis has proven its benefits, national health insur-

ance authorities have decided to fully cover it. It consists of aerobic

exercise, nutritional advice and intensive rehabilitation utilizing

Vojtas method, DNS and neuromuscular activation.

Results: All 62 patients have completed the course. Unlike in the

other patients’ groups, in this cohort we have observed 100% com-

pliance with the programme. None of our patients had to have a rectus

diastasis repair and although not all were completely reduced, with

improving trends we felt it was not necessary to operate. Only 9

patients had umbilical hernia repair so far. The smaller hernias

became asymptomatic and could be left unrepaired. With a follow-up

of 3–34 months we have not had any recurrence yet.

Conclusion(s): Female abdominal wall when stretched during preg-

nancy can result in a severe medical and psychological issue.

Abdominoplasty is not covered by the general health insurance and

for many it is not an affordable option. However, pregnancy is a

physiological process and we believe the consequences don’t always

have to lead to a surgery. The MTP has proven to be effective both in

physical and mental aspect of this complex issue.

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P-1150

The management of mesh infection after laparoscopic

inguinal hernia repair

Yang HBeijing Chaoyang hospital

Aim: With the increasing number of laparoscopic inguinal hernia

repair, the mesh infection after laparoscopic surgery is not rare

especially in large volume centers. To present our experience of

managing mesh infection after laparoscopic inguinal hernia repair in

19 patients.

Methods: Nineteen extensive mesh infection cases (2012–2017) were

included in our study, and all were managed by laparoscopic mesh

excision after preoperative workup. After mesh removal and a drai-

nage was inserted in preperitoneal space, the peritoneal flap was

closed with 3/0 absorbable consecutive suture.

Results: All the patients underwent the operation uneventfully. One

case had sigmoidectomy for fistula, and two cases need second

laparoscopic surgery for the infection on the contralateral side and for

the residual mesh around pubic bone separately. In total, three

recurrence was identified during follow up.

Conclusion: Laparoscopic mesh excision is an effective and mini-

mally invasive method to cure infection, and to avoid unnecessary

interruption of healthy layers of abdominal wall at the same time.

P-1151

Bilateral incarcerated inguinal hernia with unilateral

sigmoid adenocarcinoma containing hernia sac

successfully repaired using a robotic transabdominal

preperitoneal approach: a case report

Musonza T, Haubert L, Loor MBaylor College of Medicine

Introduction: We report a successful robotic transabdominal

preperitoneal repair of giant bilateral inguinal hernias for a patient

with an incarcerated sigmoid cancer within his left inguinal hernia.

Case report: A 52-year-old male with end stage renal disease,

hypertension, recent 5-vessel CABG, obstructive sleep apnea, distant

open appendectomy and no prior groin surgery presented with

symptomatic incarcerated bilateral inguinal hernias. These hernias

had been present for many years. However, he recently underwent

colonoscopy and biopsy of a 1.0 cm sigmoid polyp which revealed

moderately differentiated adenocarcinoma with invasion into the

submucosa. Interestingly, this lesion, which was tattooed and clipped

endoscopically, was in a portion of the sigmoid colon which resided

within his left inguinal hernia. A robotic approach to hernia repair and

sigmoidectomy was chosen to minimize morbidity associated with

large incisions. Examination of the pelvis revealed very large inguinal

defects bilaterally. Reduction of the left sided pantaloon hernia was

undertaken, in conjunction with a robotic sigmoid mobilization by the

colorectal surgeon. Sigmoidectomy and anastomosis were completed,

and the specimen extracted via a 7 cm lower midline incision. The

bilateral hernias were repaired in a transabdominal pre-peritoneal

fashion using biosynthetic mesh. The large hernia sacs were imbri-

cated at the time of peritoneal flap closure. The patient did well

following surgery. He required a brief stay in the intensive care unit

for hypovolemia. He was discharged from the hospital on post op day

8. Final pathology was negative for malignancy. Patient returned to

work 4 weeks following surgery.

Conclusion: A robotic transabdominal preperitoneal approach to

large incarcerated bilateral inguinal hernias is feasible in the re-

operative abdomen and for the multi-morbid patient. Through the

carefully coordinated efforts between surgery teams, procedures such

as these that combine hernia repair with an oncologic resection, can

be safely executed in a minimally invasive fashion.

P-1152

Analysis of sublay herniorrhaphy for elderly primary

lumbar hernia: a clinical study of 21 patients

Huadong D, Ying-mo SDepartment of Hernia and Abdominal Wall Surgery, Beijing Chao-

Yang Hosipital, Captial Medical University

Objective: To explore the safety and effectiveness of Sublay

Herniorrhaphy for Elderly Primary Lumbar Hernia.

Methods: The clinical data of 21 patients with elderly primary lumbar

hernia underwent Sublay Herniorrhaphy between January 2015 and

March 2018 in Beijing Chao-Yang Hospital of Capital Medical

University were analyzed retrospectively.

Results: Operations were completed successfully in all 21 cases. The

mean lumbar defect was (2.4 ± 0.4) cm (range 1.5–3.0 cm).The

mean operation time was (43.4 ± 13.2) min (range 25–75 min) and

the mean hospital stay was (3.0 ± 1.0) days (range 1–5 days).The

postoperative VAS pain score was (2.6 ± 0.9) scores (range2–6

scores).There were no complications such as wound infection. All

cases were followed up for 2–37 months (18.6 ± 11.3) without

obvious chronic pain, foreign body sensation and recurrence.

Conclusion: The Sublay herniorrhaphy in Elderly primary lumbar

hernia by using the preperitoneal patch is safe and feasible. Its effi-

cacy in short-term is certain.

Keywords: Lumbar hernia elderly; Preperitoneal space; patch

P-1159

Nbca chemical medical glue for mesh fixation

in inguinal hernia repair (Lichtenstein, TAPP Or TEP)

Shen Y, Qin C, Chen JBeijing Chao-Yang Hospital, Capital Medical University

Objective: Although the approach of fixing the mesh with non-ab-

sorbable synthetic suture has been adopted, it is disadvantaged by the

large number of stitches and an increased incidence of complications

such as postoperative pain, chronic pain, and hematoma or hydrops

formation. With the aim of reducing these complications, some

researchers have adapted medical adhesives in tension-free hernior-

rhaphy and have achieved satisfactory results. We conducted this

study using a novel lightweight polypropylene mesh that has been

proven to be associated with fewer complications for inguinal

herniorrhaphy to imply the effectiveness of n-butyl-2-cyanoacrylate

(NBCA) glue for mesh fixation in Lichtenstein tension-free hernior-

rhaphy and laparoscopic herniorrhaphy for inguinal hernias.

Methods: A total of 2136 patients with primary unilateral inguinal

hernia were included. In 893 cases, NBCA adhesive (Compont

Medical Adhesive, 1.5 ml/tube; Beijing Compont Medical Devices

Co., Ltd., Beijing, China) was used during Lichtenstein herniorrhaphy

while the left 1243 cases was used in the fixation of the mesh during

the laparoscopic herniorrhaphy (TAPP or TEP). Operation time,

postoperative length of stay, visual analogue scale (VAS) score,

incidence of chronic pain and hematoma formation, and hernia

recurrence were evaluated.

Results: The operative time was 36.2 ? 10.3 min and the postoper-

ative length of stay was 1.2 ? 0.6 days. The minimum follow-up was

123

S79 Hernia (2019) 23 (Suppl 1):S50–S100

24 months, there were no hernia recurrence or wound infection in

either group. The postoperative VAS score was 1.6 ? 0.7, there was

no postoperative pain occurred (visual analogue score[ 4, lasted

3 months). 13 (1.5%) hematomas occurred in the open cases and 17

(1.4%) cases occurred in the laparoscopic group.

Conclusions: Application of chemical medical adhesive in tension-

free herniorrhaphy for inguinal hernia appears to be a safe and

effective approach.

P-1161

Lichtenstein repair of indirect inguinal hernias

with biological (acellular tissue matrix) grafts

in adolescents and young adult patients (13–45 years

old)

Shen Y, Chen JBeijing Chao-Yang Hospital, Capital Medical University

Objective: To evaluate the outcomes of Lichtenstein hernioplasty

using acellular tissue matrix (ACTM) grafts in adolescents and young

adult patients (13–45 years old).

Methods: In this study, 317 patients, 13–45 years old, with primary

unilateral indirect inguinal hernias, received Lichtenstein hernioplasty

using ACTM mesh. The outcome measures were the length of the

operation, postoperative visual analogue scale (VAS) pain score,

length of hospitalization, postoperative complications and recurrence

rate.

Results: The operative time was (31.2 ? 5.8) min and the length of

hospitalization (1.4 ? 0.7) days. The minimum follow-up was

24 months, there were two postoperative wound infections (0.6%)

and fully recovered by change of dressing for 1 month; there were no

chronic postoperative pain (visual analogue score[ 4, lasted

3 months) or local foreign body sensation occurred; 13 patients

(4.1%) developed scrotal hydroceles and recovered by the scrotal

puncturation. There were no recurrences and other complications.

Conclusions: Lichtenstein hernioplasty using ACTM grafts is a safe

and available treatment in adolescents and young adult patients

(13–45 years old).

P-1162

Necrotazing fasciitis after incisional hernia repair

Rappoport J, Carrasco J, Dominguez C, Sanguineti A,

Sepulveda P, Sandoval G, Castillo C, Silva J, Jauregui CClinic Hospital, University of Chile

Introduction: Necrotizing fasciitis (NF), is a severe clinical condi-

tion with high risk of mortality. Estimated incidence is about 0.4–1

per 100.000 habitants. The mortality risk may reach about 70–80% in

cases of Toxic Shock.

Aim: The aim of the present study it’s to present a clinical case and

literature review.

Clinical case: Female, 70 years old, diabetes mellitus (DM), arterial

hypertension, recurrence urinary tract infections, with chronic

antibiotic (AB) use. Retroperitoneal tumor resected 5 years previ-

ously, tumor, colon, partial urinary and bladder resection was

performed, followed by ostomies and iliostomies. Ostomie closure

was attempted in several occasion, but failed and the patient remains

with colostomy (COL) at left flank. Developed hugh Incisional Her-

nia, 30 cm Hernia Sac, 20 cm Hernia Ring. Submitted to protocol of

Bolutin Toxin (BT) and Preoperative Pneumoperitoneum (PP), that

was interrupted because the patient developed Intestinal Obstruction.

Was submitted to surgery performing Enterolysis and Primary Hernia

Repair, closure hernia defect with flaps of the hernia sac and Onlay

Heavy Weight Polypropylene mesh. After 48 h developed FN and

Septic Shock. Emergency exploration was performed with abdominal

cavity review, that did not show septic problems. Extensive skin and

subcutaneous tissue resection was performed. Occlusion of the

abdominal defect with Vicryl mesh, 15 per 30 cm, and VAC 30 per

40 cm initially. Requiered ICU, vasoactive drugs, mechanical venti-

lation, traqueostomy, endovenous antibiotics and nutritional support

for 1 month, submitted to seven surgical explorations and finally

cutaneous flap covering the defect. Survived and egress in good

general conditions.

Comments: Patients with risk factor as DM, AB use, COL usuary,

old age, represent a high risk of developed FN and strict post oper-

atory care for early diagnosis and treatment must be enforced.

P-1164

Safety of the bupivacaine HCL collagen-matrix implant

(Inl-001) after soft-tissue surgery

Leiman D, Niebler G, Minkowitz HUniversity of Texas Health Science Center, HD Research Corp

Surgical site infiltration with bupivacaine, a common component of

multimodal postoperative pain management, results in short-lived

postsurgical analgesia. INL-001, a biocompatible and bioresorbable

bovine collagen-matrix designed for extended local delivery of

bupivacaine, is being developed for relief of postsurgical pain when

implanted in the surgical site during soft-tissue surgeries. The clinical

development program consisted of 11 clinical studies with 100 mg to

300 mg of INL-001: 7 Phase 1/2 studies; 2 pharmacokinetic (PK)-

specific studies; and 2 randomized, double-blind Phase 3 studies.

Patients in the PK and Phase 3 studies received 3 INL-001 collagen-

matrix implants, each containing 100 mg bupivacaine, or placebo

collagen-matrix implants (in Phase 3 studies only) following open

inguinal hernia repair. Overall, 892 subjects received a collagen-

matrix implant, with 66.2% of subjects receiving any dose of INL-001

(n = 612) experiencing C 1 treatment-emergent adverse event

(TEAE), and 68.2% of subjects receiving placebo collagen-matrix

implant (n = 280) experiencing C 1 TEAE. In the 2 pivotal Phase 3

studies, both of which met their primary efficacy endpoint of summed

pain intensity over 24 h, 62.3% of INL-001-treated subjects (n = 411)

and 68.8% of placebo collagen-matrix implant-treated subjects

(n = 208) experienced C 1 TEAE. In both groups, about 3% of

TEAEs were deemed to be treatment-related. Across the dataset there

was no evidence of bupivacaine toxicity or any adverse effect on

wound healing with INL-001. The results of these studies support that

INL-001 is well-tolerated and may provide an alternative method for

extended relief of postsurgical pain after soft-tissue surgeries.

P-1165

Abdominal wall reconstruction in immunosuppressed

patients: series of cases in Latin America

Cabrera P, Ramirez N, Perez C, Gonzalez A, Kadamani A,

Casas F, Roman C, Mosquera MFundacion Cardioinfantil-IC

Introduction: Abdominal wall reconstruction is considered a surgical

challenge in immunosuppressed patients due to their varying out-

comes. The purpose of these cases is to describe the surgical

treatment and the short and long-term outcomes of an abdominal wall

123

Hernia (2019) 23 (Suppl 1):S50–S100 S80

reconstruction using an anterior component separation in immuno-

suppressed patients at Fundacion Cardioinfantil, Instituto de

Cardiologıa in Bogota, Colombia.

Methods: All immunosuppressed patients who underwent abdominal

wall reconstruction using an anterior component separation surgical

technique between February and May of 2017.

Results: Patient 1: previous history of renal transplant with

immunosuppressant treatment and a recurrent incisional hernia of

13 9 10 cm, with posterior seroma that resolved. Patient 2: previous

history of lung transplant and necrotizing acute pancreatitis that

required surgical treatment with marsupialization of the pancreatic

cells and therapeutic peritoneal lavage, without any complications,

hernia of 26 9 12 cm. Patient 3: previous history of systemic lupus

erythematosus (SLE) presenting a retroperitoneal hematoma with

posterior evisceration, hernia of 26x16 cm, with posterior surgical site

infection treated with lavage, VAC therapy, and skin graft.

These three patients underwent an abdominal wall reconstruction

using an anterior component separation and placement of a high

density polypropylene mesh (30x30 cm). All patients were receiving

prednisolone and (n = 2) tacrolimus as their immunomodulatory

therapy. There was no mortality reported at 30 days and the follow-

ups at 3–6–10 months did not present hernia recurrence.

Conclusions: Abdominal wall reconstruction anterior component

separation and polypropylene mesh reinforcement is a safe approach

in immunosuppressed patients. The multidisciplinary approach, the

ideal moment for surgery, and the surgical technique chosen for each

patient constitutes the principal factors in determining a favorable

result.

P-1167

Abdominal wall reconstruction for liver transplant

patients

de la Torre J, Kurapati S, Denney BUAB

Introduction: Component separation has been established as an

effective technique for complex abdominal wall reconstruction. Pre-

vious study of component separation with acellular dermis onlay

multipoint fixation has been demonstrated to be effective. Incisional

hernias following orthotopic liver transplantation (OLT) presents a

particular challenge since immunosuppression and pre-existing inci-

sions present additional challenges for the reconstruction.

Methods: The records of 183 patients who underwent complex

abdominal wall reconstruction from 2010 were reviewed. Patients

were identified by CPT codes for component separation and a history

of liver transplantation. Information regarding the OLT was available

in all eight of the patients who underwent transplantation. Data

included date of OLT, the location of the incision placement for OLT,

diagnosis for transplantation and postoperative immunotherapy

(Table 1). Seven of the patients had a standard Chevron incision. Data

reviewed included patient demographics and comorbidities, con-

comitant procedures, and characteristics of the reconstruction such as

surgical incision. Primary data endpoints were complications fol-

lowing surgery, including recurrence.

Results: The study group consisted of 9 patients, 8 who were OLT

recipients and a single patient who was a partial liver donor. In the

study group, there were no recurrences and primary approximation of

the fascial defect was achieved in 100% of the patients. A chevron

incision was used in 66% of cases and biologic material was used in

78%. Overall morbidity was 11%, with one patient identified with

deep venous thrombosis. There were no significant wound healing

problems. In the overall group, the recurrence rate was 7% and

primary approximation of the fascial defect was achieved in 92% of

the patients. Significant complications occurred in 17%.

Conclusions: Modified abdominal wall reconstruction with compo-

nent separation and onlay biologic mesh is a reliable approach to

address hernia defects in patients who have had liver transplants.

P-1169

Left diaphragmatic hernia following thoracoabdominal

aortic repair: an unusual case

Mosquera M, Tellez L, Perez C, Castillo A, Gonzalez A,

Cabrera P, Kadamani A, Ramirez N, Roman CFundacion Cardioinfantil-IC

Diaphragmatic herniation is a rare complication, with an unknown

incidence, following any thoracoabdominal procedure. However, it

has a high risk of mortality once emergency surgery has been per-

formed due to visceral strangulation. We present the case of a

67-year-old male, with previous history of diaphragmatic rupture in

2000, who later required thoracoabdominal aortic aneurysm repair in

November 2017. 6 months later, patient presents multiple episodes of

coffee ground emesis, wherein a left diaphragmatic herniation was

documented with migration of the stomach, omentum and spleen.

Through a laparoscopic approach, the herniated contents were

reduced and a pulmonary decortication was required. Primary closure

was achieved by thoracoscopy due to pleural and pulmonary adhe-

sions as well as spleen interposition. We emphasize the importance of

clinical suspicion once the surgical precedent has been identified.

P-1172

Chronic post-operative pain strongly correlates

with patch fixation method used in tension-free inguinal

hernias repair under local anesthesia

Qin C, Shen Y, Chen JBeijing Chao-Yang hospital, Capital Medical University

Objective: To identify factors associated with post-operative chronic

pain in tension-free inguinal hernia repair under local anesthesia.

Methods: The data of 2875 cases of tension-free inguinal hernia

repair under local anesthesia, performed from January 2013 to May

2015, were retrospectively analyzed.

Results: A month later, among the 2875 cases, a total of 83 (2.89%)

patients reported post-operative pain; 3 months later, only two cases

sill have pains, and the occurrence rate is 0.69%. All the patients with

pains have not last over 6 months. Age, gender, type of hernia,

occurrence of complications and pre-existing underlying diseases

showed no correlation with chronic post-operative pain, while the

patch suture fixation method showed significant correlation

(P\ 0.001). Four fixation methods were used: 7-stitch, 5-stitch,

3-stitch and 0-stitch patch fixation. Significant differences in post-

operative pain incidence were found among the groups. The stitch-

free method did not increase postoperative complications.

Conclusion: Multiple factorial analyses demonstrated that patch fix-

ation method is an independent risk factor for chronic pains after

tension-free inguinal hernia repair under local anesthesia.

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S81 Hernia (2019) 23 (Suppl 1):S50–S100

P-1174

Effect of bupivacaine HCL collagen-matrix implants

(Inl-001) on pain and opioid use in subgroups

after inguinal hernia repair

Leiman D, Niebler G, Minkowitz HUniversity of Texas Health Science Center, HD Research Corp

INL-001 (bupivacaine HCl collagen-matrix implant) delivers bupi-

vacaine over time into the surgical wound. In 2 Phase 3, randomized,

double-blind studies (MATRIX-1, MATRIX-2), subjects undergoing

elective, open, tension-free mesh inguinal hernia repair under general

anesthesia were randomized to receive 3 INL-001 100-mg bupiva-

caine HCl matrices or 3 placebo matrices. Parenteral morphine was

available for breakthrough pain. When able, subjects began oral

acetaminophen (650 mg tid) and immediate-release morphine PRN.

Subjects assessed pain intensity (PI) using an 11-point numerical

rating scale. Sum of PI (SPI) and total use of opioid analgesia (TOpA)

in milligram IV morphine equivalents were calculated from matrix

implantation (Time 0). The primary endpoint for both studies was SPI

0–24 h (SPI24) for patients receiving INL-001 compared with pla-

cebo. Analysis of SPI24 and TOpA 0–24 h (TOpA24) was performed

for the following subgroups: sex, history of previous ipsilateral hernia

repair, age, race, body mass index (BMI), and multiple hernia history.

Data from MATRIX-1 and MATRIX-2 were also pooled. The pri-

mary endpoint was met in both studies and the pooled population

(P = 0.0004, P = 0.0001, and P = 0.0001, respectively). For all sub-

groups, SPI24 and TOpA24 were lower in the INL-001 vs placebo

arms. Decreases in SPI24 were significant for most subgroups

(P\ 0.02 each), but not in women and subjects with history of

multiple hernias. TOpA24 was significantly reduced in most sub-

groups (P\ 0.03 each), except for individuals aged C 75 years and

subjects with a history of multiple hernias. Adverse events were

reported in 62.3% of subjects treated with INL-001 and 68.8% treated

with placebo; most were mild/moderate in severity and unrelated to

study treatment. Results from 2 Phase 3 studies of subjects under-

going hernioplasty demonstrate that INL-001 is a novel bupivacaine

delivery technology that produces extended, opioid-reducing post-

surgical analgesia regardless of age, race, sex, BMI, or history of

hernia or ipsilateral hernia repair.

P-1178

Initial experience in posterior component separation

with transverse abdominis (TAR) muscle release

in a University Hospital in Chile

Quezada N, Achurra P, Jacubovsky I, Munoz R, Crovari F,

Jarufe N, Morelli C, Pimentel FPontificia Universidad Catolica de Chile

Background: Posterior component separation with TAR during

abdominal wall reconstruction for ventral hernias has become an

appealing option for the management of complex ventral hernias. We

report our initial experience with TAR in the first 30 consecutive

patients in a University Hospital in Chile.

Objective: To report our initial experience and short term outcomes

with TAR for the treatment of complex ventral hernias.

Methods: Retrospective case series of the first 30 patients with

complex ventral hernias who underwent an abdominal wall recon-

struction with posterior component separation and TAR between

December 2016 and September 2018. Demographic, perioperative

data and early outcomes were included for analysis.

Results: During the study period, 30 patients underwent an abdominal

wall reconstruction using posterior component separation and TAR.

Average age was 61 years old (range 29–83), 55% were women and

average BMI was 32. The average width of the hernia defect was

12 cm (range 3–17 cm), two patients had multiple defects and three

had parastomal hernias.

All patients underwent a complete preoperative evaluation and were

asked to lose weight before surgery and all patients achieved midline

closure. One-side TAR was performed in four patients, six patients

underwent a combined procedure (80% cholecystectomy) and 10

patients were operated by a laparoscopic eTEP approach. Average

operative time was 2.5 h.

Overall morbidity was 13%, 2 patients had an infection (one had

the mesh removed), 1 patient had a wound seroma and 1 patient had a

medical decompensation (Chronic kidney disease). Overall mortality

was 0% and 1 patient had a reoperation (for mesh removal and wound

lavage). No recurrences have been identified so far in early follow-up.

Conclusion: Posterior component separation with TAR has a safe

learning curve with promising results similar to those reported in the

literature.

P-1180

Thirty day outcomes after umbilical hernia repair:

comparison of a high volume center versus AHSQC

database

Lo Menzo E, Aleman R, Frieder J, Fonseca C, Milla C,

Ortiz Gomez C, Szomstein S, Rosenthal RCleveland Clinic Florida

Introduction: There is no consensus on the best method for umbilical

hernia repair. The aim of this study was to evaluate the 30 day out-

comes of patients undergoing primary umbilical hernia repair (UHR)

at our institution versus the American Hernia Society Quality Control

(AHSQC) database.

Methods: We retrospectively reviewed all patients who underwent

ventral hernia repair at our institution from 2012 to 2017. Common

demographics (table 1 and 2) and outcomes were collected, and 30

postoperative days outcomes were compared to the AHSQC database

(Table 3).

Results: Of the 261 ventral hernia repairs performed, 47.5%

(N = 124) were UHR. Males and Caucasians composed 64.5%

(N = 80) and 60.5% (N = 75) of our population, respectively. Dia-

betes was present in 11.3% (N = 14) and hypertension in 30.7%

(N = 38) of our patients. The mean age was 54.91 ± 15.02 with a

prevalent open repair of 73.4% (N = 91) and no use of mesh in 83.9%

(N = 104). A direct relationship was observed between operative time

less than 2 h and length of stay greater than 24 h. Our surgical site

Table 3 – 30 day postoperative complicationsSSI N (%) p=0.7290Cleveland Clinic Florida 1/261 (0.38)AHSQC (All) 51/5630 (0.91)SSO p=0.0019Cleveland Clinic Florida 4/261 (1.53)AHSQC (All) 319/5630 (5.67)SSO requiring procedural intervention p=0.1877Cleveland Clinic Florida 1/261 (0.38)AHSQC (All) 88/5630 (1.56)Re-admission p=0.0760Cleveland Clinic Florida 0/261 (0)AHSQC (All) 71/5630 (1.26)SSI: surgical site infection; SSO: surgical site occurrence

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Hernia (2019) 23 (Suppl 1):S50–S100 S82

occurrences (SSO) was 1.5% compared to the AHSQC 5.6%

(p = 0.0019). Surgical site infection (SSI), SSO requiring interven-

tion, and readmission showed a comparable incidence to the AHSQC

database.

Conclusion: Our study shows that the majority of the umbilical

hernias are done open with no mesh, with very low complications.

Our SSO rate is lower compared to AHQC, however all the other

outcome measures are comparable.

P-1181

Long-term follow-up of a randomized controlled trial

of Lichtenstein repair versus the Valenti technique

for inguinal hernia

Mitura KSiedlce Hospital, Department of General Surgery

Purpose: The aim of the study is to offer a prospective comparative

assessment of long-term outcomes for inguinal hernia repair using

Valenti and Lichtenstein techniques.

Materials and methods: 568 surgical procedures for unilateral

inguinal hernia repair using the Valenti (group V) or the Lichtenstein

technique (group L) were performed. After the mean follow-up time

of 9 years (8–12), 185 patients (70.1%) treated using Valenti method

and 186 patients (71.3%) treated using Lichtenstein method were

clinically assessed. All clinical data were registered in National

Hernia Registry. The rate of recurrence was assessed as primary

outcome. The secondary outcome involved chronic pain (VAS).

Results: 9-year recurrence rate was 2.2% in both groups. No signif-

icant difference in recurrence rate was demonstrated in analysis

adjusted for surgeon’s education, type of hernia, hernia size, hernia

duration, or BMI between two groups [OR 1.0; 95% CI 0.69–1.67;

p = 1.0]. In follow-up the majority of patients reported no pain

(71.9% in V; 73.7% in L). A constant pain was reported by 4 patients

in each group. Severe pain was reported by 1.6% in V and 2.1% in L.

Conclusions: Inguinal hernia repairs using Valenti and Lichtenstein

methods show high long-term effectiveness and do not significantly

differ in the recurrence rate. Both methods ensure a low rate of

chronic pain. The use of a single mesh size with a precisely defined

shape and of a uniform mesh fixation method ensures the standard-

ization of surgical technique. The Valenti method is an

uncomplicated, technically reproducible procedure with a low learn-

ing curve.

P-1182

The influence of different sterilization types

on mosquito net mesh characteristics in groin hernia

repair

Mitura K, Kozieł SSiedlce Hospital, Department of General Surgery

Background: In low-resource countries, a suture repair is still in

common use due to the limited access to commercial mesh implants.

The search for less expensive alternatives to the synthetic meshes has

led to using mosquito nets. Sterilized mosquito net appears to be a

low-cost and commonly available product that closely resembles

commercially available meshes. However, the extent to which ster-

ilization alters the structure of mosquito nets is still unknown. The

aim of this research was to assess the effects of different sterilization

types on physico-mechanical properties of mosquito nets.

Materials and methods: Nine different polymers were analyzed (six

mosquito nets from low-resource countries, one European net and two

commercial meshes). The analyzed parameters included: polymer

type, net surface area, fiber diameter, net thickness, mesh weight, pore

size, tensile strength and tear force. The measurements were taken

before sterilization, after sterilization at 121 �C and at 134 �C.

Results: Sterilization altered net surface and pore size, but did not

significantly alter the single fiber diameter, weave of filaments or net

thickness. Steam sterilization did not affect the tensile strength or tear

force.

Conclusions: Sterilization at 121 �C reduces the mosquito net surface

area[ 40%, resulting in a loss of macroporous structure and turning

the mesh into hard, shrunken, non-pliable masses. Sterilization at

134 �C causes some mosquito nets to melt and completely destroys

their porous structure. Maximum pressure in the abdominal cavity is

higher than the tensile strength and tear force of some locally avail-

able mosquito nets; therefore, these nets should not be used.

P-1183

Influence of ethnicity-related differences in inguinal

canal dimensions on the mesh size for open

and laparoscopic groin hernia repair in low-resource

countries in Africa

Mitura K, Kozieł SSiedlce Hospital, Department of General Surgery

Introduction: The access to surgery in Africa is significantly limited.

Treatment outcomes in Africa differ significantly compared to those

achieved in Europe or the US. Therefore, to popularise tension-free

repair, it is essential to determine the economically justified mesh size

for the African population. The aim of this study was to conduct

anthropometric evaluation of inguinal canal in African and European

patients to determine their effects on the mesh size.

Methods: The measurements were made in 44 adult males in Africa

(Group I) and were compared to measurements in 45 consecutive

Caucasian males (Group II). The mean age of patients was respec-

tively 48.3 and 51.2 years.

Results: There were no statistically significant differences in the

internal ring diameter between both (2.2 vs 2.1 cm; p = 0.58). The

distance between the pubic tubercle and the inferomedial border of

the internal inguinal ring was significantly shorter in group I (3.8 vs

5.1 cm; p\ 0.001). Similar differences were demonstrated in the

length of transverse arch aponeurosis (2.9 vs 4.0 cm; p\ 0.001). The

distance between the pubic tubercle and anterior superior iliac spine

in group I was approximately 2 cm shorter on each side (10.0 vs

11.8 cm; p\ 0.001).

Conclusions: Anatomical differences in inguinal dimensions between

Central African and European populations support the need to adjust

the standard size of synthetic mesh used for hernia repair to the needs

of local populations. The significantly smaller dimensions of the

inguinal canal in African males allow the use of smaller meshes.

P-1184

Postoperative acute pancreatitis following difficult

robotic repair of bilateral inguinal hernias

Doerhoff CCapitol Region Medical Center

Background: Post operative pancreatitis first reported by Schneider

and Sebening in 1928. For years, postoperative pancreatitis (POP)

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S83 Hernia (2019) 23 (Suppl 1):S50–S100

was described following biliary and pancreatic surgery. Later, POP

was associated with GI tract and open heart surgery. Today, POP

maybe associated with any procedure requiring anesthesia.

Discussion: Acute pancreatitis is divided between mild and severe

pancreatitis (SAP). Mild pancreatitis is treated with IV hydration,

NPO and nutrition. 20% of patients with pancreatitis are complicated.

SAP has a mortality of 15–30%. And 30% of patients with necrotizing

pancreatitis develop a secondary infection and if left untreated, have a

mortality of 100%.

Methods: 72 year old, white male with bilateral inguinal hernias.

PMHx: robotic radical prostatectomy 2 years prior and plug patch

repair of right inguinal hernia. The patient underwent robotic expla-

nation of mesh plug with repair of recurrent right inguinal hernia and

nonrecurrent left inguinal hernia using 12 cm x 15 cm preperitoneal

mesh. Fibrin was used to glue mesh to soft tissue and permanent tacks

were used to secure mesh to coopers ligament and mesh to mesh.

Peritoneum was closed with an absorbable suture. Anesthesia time

was 4 h and 45 min, operative time was 4 h and console time was 3 h

30 min. EBL 50 cc. Patient was discharged same day post opera-

tively. Patient presented to ER first post operative day complaining of

abdominal pain. Amylase was 1812U/l and Ct scan demonstrated

acute pancreatitis.

Conclusion: Etiology of POP is unclear. Morbidity and mortality of

POP is the same as any patient developing pancreatitis. POP can

occur following any procedure requiring anesthesia. POP should be

considered for a patient who complains of severe abdominal.

P-1187

Is gender really a handicap?

East BFN Motol

Introduction: In the Czech Republic (CR), political correctness and

gender equality has not reached the levels of some western countries.

Some areas of medicine remain ‘boys clubs’ with high rates of

bossing, mobbing and other forms of bullying towards woman. The

aim of this study was to look for evidence that such activity is also

prevalent in Czech surgical specialties.

Materials and methods: All available sources (National registry of

medical statistics, Ministry of education, National sociological office,

and Czech surgical society list of members) were searched for the

numbers of female surgeons and their work positions within the team

hierarchy. Social media platforms were also searched for possible

explanations for gender disparity.

Results: 1507 surgeons are registered in the Czech surgical society.

Out of the 52 honorary members, 14 board members and 132 foreign

honorary members, there are no woman. Currently, 54% of doctors

are woman but only 20% in general and 10% in orthopedic surgery.

Out of all professors only 15% are woman although more than 60% of

university assistants are female. In surgery, less than 1% of the pro-

fessors are female and none are involved in the leadership of

university facilities. Social media provided a broad spectrum of

possible explanations—woman are perceived to be less reliable, have

poorer decision making skills, lack intelligence and manual skills.

Their lower resistance to stress is also mentioned. However,

according to a recent questionnaire among health professionals,

female staff are exposed to more stress and verbal abuse, but they take

less sick days than their male counterparts.

Conclusion: Female inferiority is a myth no longer acceptable. There

is a serious lack of female role models in surgery in the CR. It is

hoped that with international initiatives and collaborations, that this

gender imbalance will be corrected.

P-1188

High mobility group box-1: potentially a key mediator

in the development of incisional hernias

Larsen N, Reilly M, Thankam D, Fitzgibbons D, Agrawal

DCreighton University School of Medicine

Patients undergoing a laparotomy have approximately a 10–20%

chance of developing an incisional hernia (IH), although these num-

bers vary widely in the literature primarily dependent on the patient

population being studied. Regardless the morbidity, mortality, and

socioeconomic impact for treating these hernias are immense.

Although many clinical factors such as smoking, infection etc. have

been correlated with the development of an IH, few studies have

evaluated the underlying molecular mechanisms. The majority of the

reports that have been published deal with the disorganization of the

extracellular matrix (ECM), alterations in type I and type III collagen,

matrix metalloproteinases (MMPs), and tissue inhibitors of metallo-

proteases (TIMPs). However, the underlying molecular mechanism

that leads to ECM disorganization is largely unknown. We hypothesis

that sterile inflammation mediated by one of the damage-associated

molecular pattern (DAMP) molecules, high mobility group box 1

(HMGB-1), is associated with the development of IH. We tested our

hypothesis in the surgically discarded IH tissue collected from the

patients who underwent IH repair surgery using immunohistological

techniques. The H&E staining revealed ECM disorganization and

inflammation in the island of tissue harvested during the concurrent

panniculectomy and hernial sac harvested from the IH patients. The

protein expression of HMGB1 and its receptors such as TLR2, TLR4,

and RAGE, and the mediators of NLRP3 inflammasome pathway,

particularly Caspase-1, NLRP3, and ASC protein, were found to be

upregulated in these tissue specimens in comparison with the normal

control tissue. Similarly, an increase was observed in mRNA tran-

scripts as determined by qRT-PCR analysis. These findings suggest an

association of HMGB1-mediated sterile inflammation in the IH tis-

sues, however, further research is warranted to investigate the role of

HMGB-1 in the molecular pathogenesis of IH. Such findings could be

critical in identifying novel therapeutic targets in the management of

IH formation.

P-1190

74 year old with loss of domain and a massive squamous

cell carcinoma of the abdominal wall

Alkhatib H, Tastaldi L, Fafaj A, Svestka M, Petro C,

Krpata D, Prabhu A, Rosen MCleveland Clinic Foundation

74 year old male with complex past surgical history presented with

complete loss of domain, a massive wound that developed squamous

cell carcinoma, foul smelling discharge, and bloody output from his

abdominal wound. His past surgical history include perforated

diverticular disease requiring hartmann’s procedure. From there, he

developed necrotizing fasciitis in the abdominal wall requiring

extensive debridement and closure via synthetic mesh and multiple

split-thickness skin grafts. Hartmann’s was later reversed and dense

abdominal adhesions were found eroding into the small bowel with

multiple small bowel abscesses. Mesh was removed and the resulting

defect was repaired using absorbable mesh. Patient went on to

develop mesh infection and chronic infected abdominal wall, which

was biopsied and showed invasive, well differentiated, squamous cell

carcinoma.

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Hernia (2019) 23 (Suppl 1):S50–S100 S84

Due to multiple issues presenting at once, a comprehensible

approach was planned and a permanent repair of the defect was

deferred. Once inside the abdomen, multiple pieces of infected mesh

were exposed and removed, and enterocutaneous fistulas were taken

down. It then became apparent that what was thought to be an

infected mesh fistula was actually the tumor eroding into the right

lower quadrant and retroperitoneum. The mass was then circumfer-

entially dissected for grossly negative margins. The bowel was also

adhered to the mass and needed to be resected. Total colectomy was

performed with end ileostomy in the lateral abdominal wall. The size

of the resected mass was 30 9 30 cm, which left a massive defect in

its place. Abdominal wall was reconstructed using split thickness skin

grafting from left thigh (450 cm sq) with implantation of a 30 9

30 cm absorbable mesh. Patient recovery was complicated by high

output stoma requiring TPN, and was discharged on POD 16.

P-1192

Outcomes following robotic ventral hernia repair

Sharbaugh M, Patel P, Zaman J, Feustel P, Singh TAlbany Medical Center

Short-term success following robotic-assisted ventral hernia repair

(RVHR) is well established, however, long-term outcomes are

unknown. In this study, we followed a cohort of patients 2 years after

RVHR to demonstrate durability and examine risk factors for

recurrence.

A retrospective analysis of RVHR performed by a single surgeon

from 2012 to 2016. The technical approach for hernia repair consisted

of primary fascial closure and a pre-peritoneal mesh when possible.

The primary end-point of recurrence was determined based on

physical exam or imaging documented in the medical record.

108 RVHRs were performed over 4 years. Mean age was

52.72 ± 13.61 years, BMI was 33.07 ± 7.82 kg/m2, and hernia

defect size was 70.1 ± 86.3 cm2. 17.6% of patients were diabetic,

13.9% were smokers pre-operatively, 72.2% were ASA class 3 or

higher, and 29.6% had prior VHR. Primary fascial closure was

achieved in all RVHRs, with 23.1% requiring component separation.

Mesh was used in 97.2% of patients; 79.5% had pre-peritoneal mesh

and 17.6 had intra-peritoneal onlay mesh. 98% of patients had long-

term follow-up at a mean of 625.6 days. Recurrence rate was 12%,

with one recurrence attributed to an inguinal hernia fixed concurrently

with a midline defect. Recurrent hernia patients were more likely to

be female (p = 0.029). Otherwise, there were no statistically signifi-

cant differences in age, BMI, ASA class, incidence of diabetes,

smoking status or number of previous hernia repairs Hernia defect

size and peri-operative complications including SSO, ileus, obstruc-

tion, or any other medical complication were not predictive of

recurrence. Technical approach did not affect outcomes.

RVHR is safe and durable with a low recurrence rate at a mean of

22 months post-operatively. Female gender is a risk factor for

recurrence.

P-1193

Exhortation to lose weight prior to complex ventral

hernia repair: nudge or noodge?

DeLong C, Ssentongo P, Ssentongo A, Pauli E, Soybel DPenn State Hershey Medical Center

Background: Weight loss is advocated for obese patients contem-

plating open complex ventral hernia repair (cVHR). In this study, we

tested the hypothesis that the prospect of a major operation such as

cVHR does not alone motivate patients to sustainable weight loss.

Methods: Data on 230 patients (BMI range 30–63 kg/m2) undergoing

cVHR from January 1, 2012, to July 30, 2017, were collected retro-

spectively and analyzed. Reviewed in each record was the interval of

1 year prior to the surgeon’s initial evaluation to 1 year after

operation.

Results: For all patients, diet and weight loss were recommended

prior to operation. At the initial office visit, 121 had been losing

weight (Group A, downward trajectory) and 109 were gaining weight

(Group B, upward trajectory). By the time of operation, 56 (46%) of

patients in Group A had continued to lose weight, whereas 69 (63%)

in Group B had been motivated to lose weight (2 (1,

N = 230) = 107.9, p\ 0.0001). Of 125 patients (Groups A & B) who

had lost weight between the first encounter with their surgeon and the

time of operation, 65 (52%) regained some/all of the weight lost

before operation; of the 105 patients (Groups A&B) who had not lost

weight prior to operation, 68 (65%) had gained more weight at 1 year

follow-up. Above 40 kg/m2, pre-operative BMI was positively and

significantly correlated with post-operative hyperglycemia (OR 2.4,

95% CI 1.27, 4.76, p = 0.008) and wound occurrence (OR 2.02, 95%

CI 1.01, 3.97, p = 0.04).

Conclusions: With conventional exhortation, pre-operative weight

loss occurred only in about half of our patients, and was often

unsustainable after operation. Exhortation to lose weight before and

after surgery is likely to be perceived more as noodge than nudge,

suggesting that individualized strategies are needed to promote long-

term healthy behaviors and outcomes in obese patients undergoing

cVHR.

P-1195

Potential predictors for hernia follow-up

after emergency department discharge

Hodgdon I, Adams E, Leonardi C, Dooley D, Nguyen QLSU HSC Department of Surgery

Background: Follow-up after Emergency Department (ED) diagnosis

of symptomatic hernias are documented as low as 23%. This is

concerning since up to 3% of unrepaired hernias will eventually

incarcerate or strangulate. We studied rates of symptomatic hernias at

our institution and investigated if demographics could predict patient

follow-up.

Methods: We looked at 1 year of ED discharges (n = 375) with

ventral or inguinal hernias. Patient sex, race, ethnicity, language,

insurance type, age, body mass index (BMI), Area of Deprivation

Index (ADI), and Charlson Comorbidity Index (CCI) was collected.

Patients received emergency surgery (EMS, n = 36) or clinic

appointment (n = 339). Follow up rate and 95% CI was calculated

excluding EMS patients using the frequency procedure of SAS.

Univariate and multivariate odds to follow-up and EMS were mod-

elled using logistics regression (proc glimmix) in SAS.

Results: Follow-up rate was 52.2% [95% CI (46.9, 57.5)]. No sig-

nificant univariate association was observed between follow-up and

sex, race, ethnicity, language, insurance type, age, BMI, ADI and

CCI. However, in a multivariate analysis, the OR to follow-up

decreased by 12% [OR 0.88, 95% CI (0.80, 0.97)] for each unit

increase in CCI. There is a univariate association between EMS and

CCI. The odds of having EMS are increased by 13% [OR 1.13, 95%

CI (1.01, 1.25)] for each unit increase in CCI, although this becomes

insignificant when gender is included in the model due to females

having higher CCI.

Conclusions: Our finding of lower follow-up rates and higher EMS

rates in older patients with more comorbidities is troubling given the

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S85 Hernia (2019) 23 (Suppl 1):S50–S100

risks posed to these vulnerable patients. We propose that institutions

modify the way they are managing older, sicker patients with

symptomatic hernias by implementing a faster ED to surgery route to

prevent follow-up loss in this population.

P-1197

Abdominal wall reconstruction with polipropilene

double mesh repair after traumatic lumbar hernia

Santos de Miranda J, Damous S, Murakami A, Yoo J,

Zuardi A, Faro Junior M, Tanaka E, Birolini C, Utiyama EClinics Hospital from University of Sao Paulo, School of Medicine

Traumatic Lumbar Hernia (HLT) presents a technical challenge due

to its anatomical region, close to bone prominence, and lesions

associated with abdominal trauma. Its surgical treatment is chal-

lenging, and there is no consensus in the literature due to the rarity of

these cases, concerning the repair technique, as well as the ideal

moment for the surgical treatment and diagnostic method to be used.

The primary objective was to verify the effectiveness of the surgical

approach with technical standardization of double mesh repair in

patients with a traumatic lumbar hernia. A prospective 30 cases series

study from 2006 to 2017, was conducted with a delayed standardized

double polypropylene repair with preperitoneal and Onlay mesh

placement, plus flank muscles reconstruction reimplanted at iliac

crest. The surgical data analysis include the relapse rate, surgical

complications, operation time, demographic characteristics of the

patients, trauma mechanisms, timing and methods used for diagnosis,

type of lesion, locations, and size of lesions. The main results found in

this study demonstrated no relapsed with one reoperation due to

chronic mesh infection. The abdominal computed tomography was

the method of choice for abdominal wall evaluation and the diagnosis,

especially at the acute phase. The delayed standardized approach was

safe and effective for the correction of traumatic rupture of the

abdominal wall. There is no physical limitation of the patients and if

the quality of life increases significantly after reconstruction of the

abdominal wall.

P-1199

Biosynthetic Scaffold mesh lowers recurrent hernia rate

in high-risk ventral hernia repair with surgical site

occurrences

Ceppa E, Parker M, Barrio M, House M, Socas J, Reed R,

Nakeeb AIndiana University Health University Hospital

Considerations for mesh use in ventral hernia repair (VHR) include

patient comorbidities and potential infection risk. Patients who are

anticipated higher risk with respect to the Ventral Hernia Working

Grade (VHWG) and CDC wound classifications tend to avoid syn-

thetic mesh in order to decrease postoperative surgical site

occurrences (SSO). A novel alternative for increased strength with

lower infection risk includes biosynthetic hybrid meshes. The goal of

this project was to assess the SSO in high risk patients who underwent

VHR with either synthetic or biosynthetic mesh over a 6-month

postoperative period. Retrospective review with data collection using

CPT4 procedural codes for ventral hernia repair in 2017 from a single

center. Associations and statistical analyses were used to compare

surgical site occurrences (SSO) in high-risk patients using either

OviTex biosynthetic or synthetic mesh. Two cohorts of 50 consecu-

tive patients who underwent VHR with OviTex biosynthetic or

synthetic mesh were compared. SSO was found in 36% of the OviTex

cohort; the majority were VHWG class 3 (61%), CDC wound

class[ II (61%), had concomitant procedures (67%), and a length of

stay (LOS) of 11 days. SSO was found in 22% of the synthetic cohort,

which included VHWG class 2 (91%), CDC wound class I (91%),

only 9% underwent concomitant procedures, and a LOS of 3 days.

Patients who underwent VHR with OviTex mesh had an increased

number of SSO, yet had higher VHWG and CDC wound classifica-

tions compared to patients receiving synthetic mesh. The OviTex

group had a higher overall number of patients with SSO but had a

significantly lower rate of hernia recurrence. Postoperative SSO

increased hernia recurrence, but less common in the OviTex group.

Overall, the data suggests that biosynthetic mesh is a more desirable

option in hernia repair in high risk patients.

P-1200

The uncommon presentation of a newborn female

with a right inguinal hernia containing testicular tissue:

a case report

McCoy K, Eveland A, Norden SStamford Hospital

An inguinal hernia is a common finding in newborn babies, occurring

more frequently in males and premature infants. This report docu-

ments the unusual finding of testicular tissue with seminiferous

tubules contained in the hernia sac of a newborn female following

open right inguinal hernia repair.

We report the case of a healthy newborn female born at 39 weeks

and 6 days by vaginal delivery with a small right-sided easily redu-

cible inguinal hernia. Her bowel sounds were active and normal

female genitalia was present. She was discharged home with outpa-

tient follow up and underwent an open right inguinal hernia repair. A

mass was noted inside the hernia sac which appeared to be gonadal

tissue adherent to the posterior wall of the sac. We took a small wedge

biopsy and then performed a high ligation of the hernia sac, which

was removed and sent for pathology. The pathology results of the

biopsy tissue showed testicular with seminiferous tubules. Inguinal

hernias in female infants are normally caused by a patent processus

vaginalis that does not obliterate during gestation. While such hernias

typically contain ovarian tissue, in this case we present the unusual

case of an inguinal hernia in a healthy female infant that contained

testicular tissue and seminiferous tubules.

P-1204

Pilot study: utilization of quantitative measures

to predict opioid usages in patient undergoing hernia

repair

Prasath V, Chen Y, Harmon J, Duncan M, Bicket M,

Adrales G, Nguyen HJohns Hopkins- Bayview Medical Center

Evidence shows patients with diagnoses of depression and anxiety

have an increased risk of substance abuse. We sought to determine

whether opioid usage after elective surgery is associated with pre-

operative depression and anxiety.

A pilot study using validated questionnaires to measure depression

and anxiety were administered pre-operatively to patients undergoing

elective inguinal herniorrhaphy, followed by standardized post-oper-

ative interviews measuring opioids and pain outcomes. We assessed

for depression severity (Patient Health Questionnaire-9, PHQ-9), risk

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Hernia (2019) 23 (Suppl 1):S50–S100 S86

of opioid misuse (Screener and Opioid Assessment for Patients with

Pain-Revised, SOAPP-R), anxiety (Anxiety Sensitivity Index, ASI)

and catastrophizing (Pain Catastrophizing Scale, PCS) pre-opera-

tively. We compared patients with high use of opioids after surgery

([ 5 pills) to those with low/no opioid use.

Of 12 patients recruited, most were male (83%) and white (75%),

with median age 59 (IQR 57–64). A majority of repairs were per-

formed laparoscopically (67%), while four (33%) underwent open

repairs. Three (25%) patients were taking pain prescriptions pre-op-

eratively and two (17%) of the three were taking oxycodone. All

patients were prescribed Oxycodone (5 mg tabs) after surgery, with 8

high users and 4 low/no opioid users. Compared to low/no users,

regular opioid users had a higher baseline catastrophizing, with sig-

nificantly higher scores in the area of Rumination (p = 0.029) and

Magnification (p = 0.028) but not Helplessness (p = 0.093). High

opioid users’ median PCS score was 15 points higher, their median

ASI score was 5 points higher, their median PHQ-9 score was 2 points

higher, and their median SOAPP-R score was 4 points higher than

low users. This places them at a greater risk for misusing opioids

taken in the long-term.

There may be a correlation between a patient’s post-operative

opioid usage and their depression severity, anxiety sensitivity, or pain

catastrophizing measured with PHQ-9, ASI, and PCS, respectively.

P-1205

Incisional hernia repair after orthotopic liver

transplant: a match control study

Lo Menzo E, Ortiz Gomez C, Romero Funes D, Frieder J,

Fonseca Mora M, Milla Matute C, Szomstein S, Rosenthal

RCleveland Clinic Florida

Background: The Incidence of ventral incisional hernia (VIH) after

orthotopic liver transplant (OLT) has been reported up to 30%.

Transplant patients have an increased risk of complications and a

higher rate of recurrence after VIH repair. The aim of this study is to

determine the outcomes of VIH after OLT.

Methods: All the patients who underwent VIH at our institution and

recorded the American Hernia Society Quality Collaborative

(AHSQC) were reviewed from November 2012 to August 2018.

Patients who had previous OLT were identified and matched in a 1:1

to a control population by age, gender, BMI and comorbidities.

Postsurgical outcomes were compared.

Results: A total of 677 patients were reviewed, of which 49% (315)

underwent VIH and 51% (362) primary ventral hernia repair. From

the VIH repair group, 2.85% (9) had history of previous OLT. We

observed a homogeneous population regarding gender and predomi-

nant white ethnicity in both groups. Transplant patients were noted to

have a higher preoperative ASA score compared to control (77.78%

vs 44.44%, p = 0.1469). The most common type of repair was

laparoscopic for OLT and control groups (55.56% and 77.78%,

respectively). Patients in the control group were found to have a

shorter Length of Hospital Stay (LOS) and a predominant operative

time less than an hour (0.25 ± 0.71 vs 3.43 ± 1.72, p = 0.0003 and

11.11% vs 55.56%, p = 0.0455; respectively). Patients in the trans-

plant group had significantly larger defects (13.11 ± 8.88 vs

5.44 ± 2.30, p = 0.0233 for length and 12.67 ± 9.760 vs

5.00 ± 2.00, p = 0.0346 for width). No readmissions, reoperations or

complications were reported in any of the groups.

Conclusions: VIH repair seems to be safe in patients with history of

OLT. VIH defects in this population tend to be larger compared to

other causes of VIH. Consequently, longer LOS and Operative times

were observed for this population.

P-1206

Open ventral hernia repair (VHR)

with panniculectomy, panniculectomy denied

by insurance and without panniculectomy

Arnold M, Otero J, Huntington C, Prasad T, Colavita P,

Augenstein V, Heniford BCarolinas Medical Center

Aims: Open VHR with concomitant panniculectomy (CPVHR)

allows for excellent operative exposure and excision of poor quality

tissue. However, insurance denial often limits concomitant pan-

niculectomy (DPVHR). This study compares outcomes of patients

undergoing CPVHR, DPVHR, and those not offered panniculectomy

(NOVHR).

Methods: A prospectively collected database was queried

(1999–2017). QOL was assessed with the Carolinas Comfort Scale

(CCS). Pairwise and multivariate analysis (MVR) compared NOVHR,

CPVHR, and VHRDP.

Results: 2158 patients underwent 1529 NOVHR, 587 CPVHR, and

55 DPVHR. DPVHR were younger compared to NOVHR and

CPVHR (53.4 vs. 56.7 vs. 57.3; p = 0.03), had larger defects

(304.4 cm2 vs. 285.1 cm2 vs. 146.5 cm2), more frequent preperitoneal

mesh placement (94.1% vs. 83.2% vs. 93.0%), and components

separation (64.8% vs. 35.0% vs. 53.7%); (all p\ 0.0001). CPVHR

had more diabetics than NOVHR or DPVHR (34.7% vs. 20.8% vs.

31.4%), higher BMI (36.7 vs. 32.2 vs. 35.3), and more previously

failed hernias (75.8% vs. 54.2% vs. 74.6%); (all p\ 0.001). On

pairwise analysis there was no significant difference between

NOVHR, CPVHR, and DPVHR in outcomes including length of stay

in days (6.8 vs. 8.2 vs. 6.5), readmission (7.1% vs. 14.0% vs. 9.3%),

hernia recurrence (10.6% vs. 7.4% vs. 1.9%), seroma (17.7% vs.

23.6% vs. 22.6%), or cellulitis (8.5% vs. 17.4% vs. 7.6%). On MVR,

CPVHR had increased odds of wound complications (OR 1.5, CI

1.01–2.4), but no difference in hernia recurrence (OR 1.3, CI 0.6–2.6),

pneumonia, respiratory failure, or readmission. QOL at 1, 6, 12, and

24 months was equivalent between groups in all CCS domains.

Conclusion: Panniculectomy during VHR is associated with

increased complications, but has equivalent quality of life. CPVHR

was not associated with hernia recurrence on MVR. This may be due

to increased use of CPVHR in contaminated surgical fields. This data

suggests that concomitant panniculectomy can safely be offered to

select patients, but is not a routine component of ventral hernia repair.

P-1207

Endoscopic-assited linea-alba reconstruction plus mesh

fixation for treatment of umbilicus hernia, epigastric

hernia and rectus abdominis diastasis: preliminary

results of a single center

Youssef M, Brasil H, Amaral P, Barros P, Altenfelder Silva

R, Barchi L, Pivetta L, Roll S, Zilberstein BSanta Casa de Sao Paulo School of Medical Sciences

Aim: The management of primary ventral hernias with contiguous

rectus diastasis remains debatable. We aim to report our initial

institutional outcomes with a laparoscopic-assisted plication of rectus

diastasis (RD) with concomitant ventral hernia repair.

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S87 Hernia (2019) 23 (Suppl 1):S50–S100

Methods: Consecutive patients who have undergone the repair of

umbilical or epigastric hernias associated with contiguous RD were

identified in a prospectively maintained database. Surgeries involved

a laparoscopically-assisted dissection of the subcutaneous space along

with closure of the hernia defect and plication of RD with barbed

sutures in a running fashion. A permanent synthetic mesh in onlay

position was placed and fixated with adhesives. Outcomes included

wound complications, unplanned reoperations, length of hospital stay

and hernia recurrence. Recurrence was determined either by clinical

examination, imaging studies or using the Ventral Hernia Recurrence

Inventory.

Results: Fifteen patients were identified (mean age 47 ± 10, BMI

26 kg/m2 and 80% males). Mean hernia width was 3 cm (± 1) and

60% patients had concurrent umbilical and epigastric hernias in

addition to the RD. Mean operative time was 110 min (± 16), there

were no intraoperative complications or conversions. All patients

remained with closed suction drains in place for an average of

15 days. There were three surgical site infections (2 superficial, one

deep), and one patient demanded mesh removal due to mesh infec-

tion. After a median 18 months (IQR 17–22) follow-up, recurrence

rate was 13.3%.

Conclusion: Preliminary results of this technique when performed at

our institution appear favorable. Further studies with multi-institu-

tional experiences and larger number of patients are necessary to

determine the role of this surgical technique in the armamentarium of

the hernia surgeon.

P-1208

Outcomes of incisional hernia repair in obese patients

from the AHSQC database: a single institution

experience

Lo Menzo E, Ortiz Gomez C, Frieder J, Fonseca Mora M,

Milla Matute C, Bellini A, Szomstein S, Rosenthal RCleveland Clinic Florida

Background: Obesity has been associated with an increased rate of

complications and a higher rate of recurrence after incisional hernia

repair. We aim to determine the effect of BMI in the laparoscopic and

open approach for incisional hernia repair.

Methods: We reviewed our prospectively recorded data in the

American Hernia Society Quality Collaborative (AHSQC) from

November 2012 to August 2018. Patients who underwent incisional

hernia repair at our institution were included. The population was

divided into two groups, BMI C 30 and BMI\ 30 and an indepen-

dent analysis was done for laparoscopic and open approaches in both

groups. Description of basic demographics and comorbidities was

performed. ASA scores, number of prior recurrences and outcomes

were compared.

Results: A total of 643 patients were reviewed from which 49% (315)

underwent incisional hernia and 51% (328) ventral hernia repair.

From the incisional hernia group, 56.19% (177) had a BMI C 30 and

41.90% (132) a BMI\ 30. We observed a predominant male and

white population and a similar mean age in both groups

(60.09 ± 0.78 vs 60.78 ± 0.97; p = 0.5766). Obese patients were

noted to have a higher preoperative ASA compared to non-obese

(ASA3 47.48% vs 24.17%, p = 0.0004 and 52.63% vs 24.39%,

p = 0.0098; laparoscopic and open approach respectively). Although

not statistically significant, there was a trend for obese patients to

have the procedure done open (67.57 vs 38.13, p = 0.0950, and 32.43

vs 42.10, p = 0.2333; respectively). There was no statistical differ-

ence between obese and non-obese regarding operative time,

readmission or reoperation rate for either laparoscopic or open

approach. However, a higher laparoscopic-to-open conversion rate

was observed in the obese population (4.52 vs 1.52, p = 0.1958).

There was no statistically significant difference in defect-size for

either group. Length of stay (LOS) was significantly lower in the non-

obese population who underwent laparoscopic repair.

Conclusions: Obese patients have a higher laparoscopic-to-open

conversion rate. Although complication rates in obese and non-obese

patients did not differ in either approach, obese patients who under-

went laparoscopic repair seem to have a longer LOS.

P-1209

A case of a spermatic cord sarcoma following

a laparoscopic bilateral inguinal hernia repair

Eid M, White BDartmouth Hitchcock Medical Center

Soft tissue sarcomas of the genitourinary tract are exceedingly rare

malignancies with spermatic cord sarcomas accounting for less than

2% of all urologic tumors. While these typically present as painless

slow growing testicular masses, we describe a case of a spermatic

cord myxofibrosarcoma presenting as a recurrent inguinal mass a

month after a bilateral laparoscopic inguinal hernia repair.

A 57 year-old gentleman presented to his general surgeon with a

recurrent right groin mass 1 month after a laparoscopic bilateral

inguinal hernia repair. The post-operative course was uncomplicated,

and the mass was asymptomatic.

On exam, he had a non-reducible, firm painless right groin mass in

the location of his previous hernia. Physical exam confirmed

intrascrotal location of bilateral testis and ultrasound of the right

inguinal canal revealed a solid 4x3 cm lesion with vascularity. The

patient was offered core needle biopsy to help establish tissue diag-

nosis, but he desired direct surgical intervention.

At the time of open right inguinal exploration, a solid mass was

found along the spermatic cord, initially thought to be possible

ischemic lipoma after laparoscopic repair. Frozen section pathology

demonstrated an 8.5 cm invasive malignancy. Intraoperative urologic

consultation was obtained, and a sarcoma was considered the likely

diagnosis. The patient underwent an oncologic resection of the mass

with a right radical orchiectomy and high ligation of the spermatic

cord. Final pathology was consistent with high grade myxofibrosar-

coma and he underwent post-operative XRT to the right groin.

This case illustrates the small but real potential of failing to

diagnose inguinal canal neoplasm at time of laparoscopic inguinal

surgery. Malignancy and the need for potential orchiectomy should

strongly be considered in any vascularized, solid masses of the

inguinal canal arising even after seemingly uncomplicated laparo-

scopic inguinal hernia surgery.

P-1210

Morbidity and readmissions after laparoscopic

recurrent inguinal hernia repairs: comparison

to NSQIP database

Lo Menzo E, Frieder J, Sarmiento-Cobos M, Milla Matute

C, Ganga R, Rammohan R, Szomstein S, Rosenthal RCleveland Clinic Florida

Background: The outcomes of laparoscopic repair of recurrent

inguinal hernia after previous open repair are not frequently reported.

We report short term outcomes over the last 5 years and compared

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Hernia (2019) 23 (Suppl 1):S50–S100 S88

them to the National Surgical Quality Improvement program (NSQIP)

database.

Methods: We retrospectively reviewed our laparoscopic recurrent

inguinal hernia repairs performed between 2010 and 2016. The

30 day readmissions, reoperations and post-operative complications

were compared to same outcomes from NSQIP. To reduce the effect

of confounding factors we used propensity case match. All tests were

two-tailed and performed at a significance level of 0.05.

Results: A total of 176 cases from our institution were compared to

3431 of the NISQIP database. Base line characteristics and co mor-

bidities were significantly different between the groups prior to the

match. Our cohort had older patients (64.8 ± 13.8 vs 61.83 ± 15.38

p\ 0.001) with higher incidence of renal Failure (18.75 Vs 0.15,

p\ 0.001) and CVA (7.95 vs 0.06,\ 0.001). Following the

Propensity case match, the reoperation rates, post op wound infection,

post op PE, post op renal failure and post op bleeding rates were

similar. However, 30 day readmission (14.77 vs 3.64, p\ 0.001),

pneumonia (1.7 vs 0.11, p = 0.01), urinary retention (5.11 vs 0,

p\ 0.001) were higher in our cohort. The operation time was higher

in our population (98.3 ± 39.89 vs 73.06 ± 44.76 p\ 0.001).

Conclusion: We conclude that the higher 30 day readmission,

pneumonia and urinary retention are attributed to the increased age

and comorbidities in our cohort.

P-1211

Intercostal incisional flank hernia after open

nephrectomy: a case report

Santos de Miranda J, Batistela F, Damous S, Faro Junior

M, Zuardi A, Yoo J, Tanaka E, Birolini C, Utiyama EClinics Hospital, Sao Paulo School of Medicine

Intercostal hernias are rare protrusions from abdominal contents due

to the previous incision at the lateral abdominal wall. They are seen

most commonly at the lower part at the lateral abdominal wall nearby

weak portions like the inferior lumbar triangle. Even when the ribs

protect the lateral intercostal area if a herniation is present, the patient

has a high risk of incarceration and strangulation. Retroperitoneal fat,

the liver, small and large bowel, even the stomach and the spleen can

be present as a hernia contend. We present a successful case of a

single mesh polypropylene preperitoneal repair. An 83-year-old

female patient was treated at Abdominal Wall Surgery Group from

the III Clinical Division at Clinics Hospital, Sao Paulo School of

Medicine. She had a past medical history of hypertension and right

open nephrectomy with 20 cm incision at the age of 69, due to renal

cell carcinoma. There isn’t any complication after this procedure.

After 6 months appeared a progressive bulging at the primary incision

portion, just between the 10th and 11th intercostal space. The patient

does not look for medical treatment because of the few symptoms.

The bulged increase and the patient complained of high degree pain

during Valsalva. The computer abdominal tomography confirms the

diagnostic and reveals the right hepatic lobe into the hernia sac. An

open surgical procedure was done with an incision at the site of the

previous one, following extensive preperitoneal dissection with full

reduction of the abdominal content. The hernia sac was resected and

closed by continuous absorbable sutures. A synthetic, monofilament,

nonabsorbable high large pore polypropylene mesh reinforced the

weakness incisional area and was fixed by six rapid absorbable stit-

ches at the preperitoneal space previous dissected. After 1 year

follow-up, the is no recurrence and all symptoms resolved.

P-1213

Epidemiological profile of patients diagnosed

with abdominal wall hernias in a public hospital

in Salvador

Pedreira Junior N, Bastos C, Santos F, Santana Neto O,

Cunha V, Guimaraes V, Rivison M, Cunha LHospital Geral Ernesto Simoes Filho

Introduction: Complex hernias have an increased difficulty and a

high time consumption for the surgical treatment. According to the

guidelines of the European Society of Hernias, we can define it as

complex by analyzing various criteria, such as its size, location, tissue

condition, patient history and previous abdominal surgeries. Other

important criteria are related to the presence of obesity, malnutrition

or diabetes. The correct surgical indication aims to circumvent the

difficulties of the treatment and restore the functionality of the

abdominal wall of these patients, exposing it to the lowest possible

risk.

Metodology: This is a descriptive, prospective, case-series study of

patients diagnosed with a complex hernia, using retrospective infor-

mation obtained from the surgical protocols and patient’s charts at the

Ernesto Simoes Filho General Hospital (Salvador, Bahia, Brazil), as

well as the literature reviews.

Results: During the study, 61 patients were admitted at the abdominal

wall ambulatory. 43 were woman, representing 70.4%. The mean age

was 54.6 years, varying from 31 to 80. Obesity was present in 56.3%

of the patients and overweight in 25.5%. 50% of the patients had

systemic arterial hypertension. The classification was mainly inci-

sional (93.4%) and 39.7% had a history of recurrence. 4 patients

relapsed more than 4 times. Regarding the location of the hernias,

81% of the patients presented midline hernias; 5.1% iliac fossa; 5.1%

inguinal; 3.6% inguinoscrotal; 3.6% subcostal; 1.8% lumbar. There

was a loss of domain in 67% of the cases.

Conclusion: The high prevalence of the epidemiological character-

istics demonstrated (age, gender, obesity, associated comorbidities,

presence of incisional hernia, mainly in the midline, and loss of

domain) emphasizes the importance of knowing the clinical profile of

hernia patients to the definition of its diagnosis, complexity and future

surgical therapy.

P-1214

Concomitant panniculectomy with complex ventral

hernia repair: increased surgical site occurrences does

not alter recurrence rates

Alimi Y, Devulapali C, Caso R, Jackson B, Falola R, Sosin

M, Evans K, Nahabedian M, Bhanot PMedstar Georgetown University Hospital

Background: Ventral Hernia Repairs (VHR) in obese patients can

have high complication and recurrence rates, partially contributed

from excess anterior abdominal skin and subcutaneous tissue

inhibiting exposure and adding tension to the repair. Studies exam-

ining the safety of a combined procedure have yielded conflicting

results. We appraised our outcomes with combined VHR/pan-

niculectomy in comparison to a matched cohort of patients receiving

VHR alone.

Methods: A retrospective review was conducted on all patients

undergoing VHR ± panniculectomy from 2007 to 2017. The

VHR/panniculectomy group was matched 1:1 by age and BMI to

VHR alone. All panniculectomies were performed by a plastic sur-

geon. Patient demographics, comorbidities, operative variables, and

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S89 Hernia (2019) 23 (Suppl 1):S50–S100

outcomes were collected. Descriptive statistics and Chi squared test

were used to compare the two groups.

Results: A total of 43 patients underwent VHR/panniculectomy and

were matched by age and BMI to 41 patients undergoing VHR alone

(n = 84). Two patients from the VHR/panniculectomy were unable to

be matched because lack of a patient with comparable BMI in the

VHR group. There was no significant difference between the two

groups in regard to patient demographics, comorbidities, and opera-

tive variables. There was no significant difference in the overall

complication rates between VHR/panniculectomy and VHR alone

groups (33 v. 20%, p = 0.17). Surgical site occurrences were signif-

icantly higher in the VHR/panniculectomy group (30 v. 10%,

p = 0.02). However, the hernia recurrence rate was identical at 7%.

Conclusion: Complex ventral hernia repair with concomitant pan-

niculectomy in obese patients is associated with increased risk for

surgical site occurrences. However, the long-term recurrence rate is

not affected. Additionally, the improvement in patient satisfaction and

quality of life with panniculectomy should be considered.

P-1215

Opioid prescribing trends in the acute surgical setting

Hlavacek C, Frey A, Wood BBrookwood Baptist Health, General Surgery Residency

Background: Opioid overdose is the leading cause of injury-related

death in the United States. Majority of current narcotic research

studies chronic pain and does not address the acute surgical setting.

Alabama is consistently one of the highest opioid prescribing states in

the country. Our project sought to evaluate our program’s prescribing

trends compared to other non-affiliated surgeons and to actual patient

need.

Methods: A survey was distributed to all Brookwood Baptist (BB)

surgeons and residents, as well as to non-affiliated surgeons in an

online forum, the National Robotic Surgery Collaboration (non-BB).

The various narcotics prescribed were compared using Morphine

Milligram Equivalent (MME) conversion. Prospective data was col-

lected for 50 robotic inguinal hernia repairs performed by the same

surgeon. All patients were discharged the same day and given 30

Norco/Percocet 7.5 mg. On the first postop visit, patients reported

how many pills they had required. Student t-tests were used to

compare prescriber habits.

Results: There were 80 survey respondents, 32 BB and 48 non-BB.

BB-affiliated surgeons prescribed significantly higher MME than non-

BB surgeons; on average 55% more (158.1 vs. 102.2, p\ 0.001). BB

residents and faculty did not exhibit differences in prescribing trends

(p = 0.62). The quantity of narcotics consumed at the first postop visit

in the prospective study averaged ten 7.5 mg Norco/Percocet or 76.1

MME.

Conclusion: Compared to current literature recommendations (75

MME), majority of surgeons, BB and non-BB, are prescribing too

many narcotics after inguinal hernia repair. Our study shows that

patient need is representative of this ideal 75 MME recommendation.

With this information, surgeons have a unique opportunity to modify

their prescribing trends and potentially help tackle the opioid epi-

demic by decreasing the possibility for postop opioid dependence and

eliminating excess narcotics that may be distributed to unintended

persons.

P-1217

Correlation of mesh size and ileus with laparoscopic

ventral hernia repair

Albertson S, Figueroa C, Smith M, Barrios CUniversity of California, Irvine

Laparoscopic repair has become a widely popular technique for

ventral hernias. One significant complication is post op ileus. This can

lead to discomfort and prolonged hospital stay for the patient. We

hypothesized that mesh size/surface area would correlate with the

development of ileus. Methods: We analyzed the data of 75 patients

that underwent laparoscopic ventral hernia repair with mesh. Logistic

regression was used to relate mesh size to the development of ileus.

Student’s t test was used to compare hospital length of stay in patients

with and without ileus.

Results: Ileus developed in 7 patients. Patient with ileus had a larger

mesh size but this did not achieve statistical significance (309 v 261,

p = 0.41). There was an increased odd ratio of 1.02 per 10 cm

squared. In other words, each 10 cm squared increase in size

increased the risk of ileus by 2% but again this did not reach statistical

significance. There was a significant difference in hospital length of

stay in patients with ileus v no ileus (7.7 v 2.5 days).

Discussion: Our data indicates that patients with ileus after laparo-

scopic ventral hernia repair experience significantly longer hospital

stays. However, increasing mesh size only weakly correlates with

increase in risk for ileus and is not predictive of which patients may

develop an ileus. Therefore, consideration of mesh size will not assist

in assessing which patient s may benefit from longer post op obser-

vation. Further studies to assist in the determination of patients at risk

for ileus after ventral hernia repair are warranted.

P-1218

Does preoperatve American Society of Anesthesiologists

(ASA) classification predict the risk of recurrence

after incisional hernia repair?

Lo Menzo E, Maria F, Cristian M, Joel F, Camila O,

Samuel S, Raul RCleveland Clinic Florida

Introduction: The ASA classification system is performed preoper-

atively to assess the risk of complications during surgery, however no

evaluation among each category has been conducted to its possible

association with hernia recurrence. The purpose of the study is to

determine the correlation between ASA classification and likelihood

of incisional hernia recurrence.

Methods: After IRB approval, we reviewed all patients entered in the

AHSQC database from July of 2012 to September of 2018. Patients

with recurrent incisional hernia repair were compared to patient who

had incisional hernia repair for the first time. The population was

matched for age and gender in a ratio 1:2. Assessment for physical

functional status prior to surgery was performed.

Results: Of 337 patients with incisional hernia, 116 patients had

recurrence. After matching populations; the overall mean age was

59.3 ± 12.3 years, leaded by male in 53% (n = 180). Predominance

of ASA class among recurrent and not-recurrent incisional hernia

patients was as follows; ASA Class 3 in 51% (n = 53) and 35%

(n = 79) respectively, followed by ASA Class 2 in 49% (N = 57) and

58.3% (n = 129) respectively. Additionally, ASA Class 1 and 4 were

predominant in the recurrent hernia group. When analyzed the

recurrent group alone; no statistical significance was found for

reoperation (p = 0.9) or operative approach used (p = 0.42). Wider

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Hernia (2019) 23 (Suppl 1):S50–S100 S90

defect size and wider mesh was not correlated to ASA class 3

(p = 0.000 and p = 0.001 respectively). Hernia and mesh width for

ASA class 3 of 8.1 cm (range 1.5–22 cm) and 16.5 cm (range

7–33 cm) respectively followed by ASA class 2 on Average 7.3 cm

(range 2–22.5 cm) and 15.8 cm (range 4–30 cm) on average respec-

tively. The likelihood of having a larger or wider hernia was not

statistically significant for any of the cases (p = 0.22 and p = 0.48

respectively).

Conclusion: The individual ASA score does not predict the risk of

recurrence, nevertheless patients with wider defects and recurrent

incisional hernias are often categorized among ASA classs 2 or 3.

P-1219

Use of progressive pneumoperitoneum in the repair

of giant inguinal hernia

Sanchez-Montes IGeneral Hospital Tlahuac

Introduction: Giant inguinal hernia are usually found in developing

countries due to delay in seeking medical attention. The operative

treatment of giant inguinal is a challenge for surgeon. Often obesity,

renal and cardiopulmonary diseases are predisposing factors for the

development of those hernias. Goni Moreno (1947) was the first the

use of progressive pneumoperitoneum with successful. The aim of

this technique is insufflation of air into the abdominal cavity in order

to make room to accommodate herniated viscera, through of catheter

in abdominal wall and to avoid in postoperative abdominal com-

partment syndrome.

Purpose: The purpose of this paper has presented the results using a

progressive pneumoperitoneum repair technique apply in giant

inguinal hernia.

Materials and methods: From 2001 until 2018 progressive pneu-

moperitoneum (PP) has been performed 6 patients with giant inguinal

hernia. Five of them had primary hernia and one had a recurrence.

The mean age of the patients was 65.5 (65–91) years. The BMI was a

mean 32.36. All of them had concomitant diseases such as hyper-

tension, chronic obstructive lung disease or diabetes. The PP

technique involves insufflating natural ambient air into abdominal

cavity by Tenckhoff catheter dialy from 400 to 1000 cc per day over

7–14 days. Every day measures urinary volume, abdominal circum-

ference, and every 2 days creatinine and urea were determined. It had

used low dose heparin prophylaxis during all procedure. It perfor-

mance inguinal repair by general anesthesia, in five patients used

Lichtentein technique and one was Rives with polipropilene mesh.

Results: All patients complained nausea, and loss weight because

they did not have appetite by abdominal distention. Only one patient

in postoperative had big hematoma, required orquidectomy.

Conclusion: The use of PP in the repair of giant inguinal hernia

avoids complication like abdominal compartment.

P-1220

Surgical site occurrence following abdominal wall

reconstruction within the 30-day postoperative period:

an AHSQC analysis

Lo Menzo E, Maria F, Cristian M, Carlos R, Camila O,

Rene A, Samuel S, Raul RCleveland Clinic Florida

Introduction: The component separation technique has been widely

used for large incisional hernia repair. The aim of this study is to

report the incidence of surgical site occurrence requiring procedural

intervention (SSOPI) after open ventral hernia repair with abdominal

wall reconstruction (AWR).

Methods: After IRB approval, we reviewed all the patients entered in

the AHSQC database from July of 2012 to September of 2018.

Patients who had AWR were then selected for the study. Stratification

depending on the size of the defect and SSOPI was performed. SSOPI

was defined as need for the following types of re-intervention: wound

reopening, debridement suture excision, percutaneous drainage, or

mesh removal during the 30-day postoperative period. The hernia size

was measured by preoperative CT-scan.

Results: From a total of 643 patients, AWR was performed in 2.48%

(n = 16) patients. SSOPI was found in 25% (n = 4) patients presented

regardless of the hernia width (HW). The average age of the study

group was 59.13 years. When the patients were stratified by hernia

size, 25% (4 out of 16) developed SSOPI. Of which all had hernia

defect size average of 17.9 cm (SD 15; range 10–25 cm) of Length

and 15 cm (SD 4.8 cm; range 13–22.3 cm) of width. Among the

patients who did not developed SSOPI; 75% (n = 12), the defect size

was 13.3 cm (SD 5.2; range 5–17.2 cm) and 12.1 cm (SD 3.8; range

6.2–13.5 cm) for length and width respectively. No statistical sig-

nificance was found between the groups for length (p = 0.13) or width

(p = 0.22). After multivariate analysis the type of mesh was statisti-

cally significant (P = 0.41), and permanent synthetic vs biological

mesh were statistically significant (p = 0.05). Non-healing wound had

higher Hernia length (25 cm) and HW (22.3 cm) when compared to

deep surgical site infections and seroma. Appropriate treatment was

given without complications.

Conclusion: The initial hernia size and the location of the mesh did

not seem to be a predictor of developing surgical site occurrence

requiring procedural intervention after open ventral hernia repair with

abdominal wall reconstruction, however the type of mesh must be

considered when intervened.

P-1223

Indications and results of the use of progressive

preoperative pneumoperitoneum (Ppp) in patients

with complex hernias with loss of domain

Pedreira Junior N, Mendes R, Dutra V, Santos F,

Guimaraes V, Cerqueira C, Cunha L, Cancado AHospital Geral Ernesto Simoes Filho

Introduction: PPP is used in correction of complex hernias with loss

of domain (LD). It promotes an increase of abdominal cavity volume

(ACV), reestablishes the intra-abdominal pressure (IAP) and

diaphragmatic function. Literature indicate it when relation between

hernia sac volume (HSV) and ACV (LD) is greater than 20–25% or in

large defects.

Methods: Prospective study on the effects and results of the use of

PPP in cases of complex hernias with LD, attended to by the

abdominal wall group of Ernesto Simoes General Hospital, in Sal-

vador, Bahia, Brazil. The analyzed variables were: gender, age, BMI,

indications, time, total gas volume and complications of PPP and

increase of ACV.

Results: From August 2017 to July 2018, PPP was used in 9 cases.

Mean age was 56 years (38–79), female (60%), mean BMI at

admission 30.4 (19.1–46.5), mean volume ratio 43% (8%–114%),

mean total gas volume was 15.2 L (7.5 L–28 L) and mean ACV

increase was 58% (13–106). About 5 patients had dyspnea, 1

abdominal pain, 1 nausea and vomiting, 1 shoulder pain, 3 had no

symptoms associated with PPP.

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S91 Hernia (2019) 23 (Suppl 1):S50–S100

Discussion: Tanaka, et al., systematized the volume calculation by

CT and performed PPP when LD[ 25%. Sabbagh, et al. used PPP

when LD[ 20%, because there may be already a risk of an increase

in IAP and need for viscerorreduction. Torregrossa-galud, et al. used a

mean total ambient air volume of 8.6 L (4.5–13.3 L), with daily

insufflation of 500–1400 ml for 13–16 days. Renard et al., used

2000 ml/day for 14 days. During the study, the daily and total mean

of infusions performed was similar to the literature.

Conclusion: This study presents results in accordance with the lit-

erature. However, there is no consensus on standardization on the best

technique, indication and time used in literature.

P-1225

Results of component separation technique

in a Brazilian Public Hospital: series of cases

Pedreira Junior N, Dourado M, Santana Neto O, Mendes R,

Guimaraes V, Cancado A, Cunha LHospital Geral Ernesto Simoes FIlho

Introduction: The component separation technique (CST) is one of

the multiples options for repair of large abdominal wall defects,

correction of hernias related to multiple approaches, necrosis or

infection of abdominal wall. The technique is based on an advance-

ment flap of the rectus abdominis muscle, which allows

reconstruction of the abdominal wall, maintaining adequate tension

and preserved physiological function. When correctly indicated, it

presents low complication rates, and the previous CST presents a rate

of 10% of relapses, compared to 30% of recurrences, when a large

ventral hernia surgery is used.

Methodology: This is a descriptive, prospective, case-series study of

patients diagnosed with a complex hernia, using retrospective infor-

mation obtained from the surgical protocols and patient’s charts at the

Ernesto Simoes Filho General Hospital (Salvador, Bahia, Brazil), as

well as the literature reviews.

Results: For this study, the component separation technique was

applied in patients with hernial ring diameter greater than 10 cm, in

elective surgeries in patients followed by the complex hernia outpa-

tient clinic HGESF. Data from 12 patients (n = 12) were analyzed,

being 6 men and 6 women, with a mean BMI of 30.6, who had

incisional hernias. Only 3 had a history of recurrence, with an average

of 2 relapses per patient. 8 presented giant defects ([ 15 cm), and 4

had a large defect (10–15 cm), with an average defect of 16 cm. The

screen was placed as onlay in all patients, underwent general anes-

thesia, with an average surgical time of 4 h (± 2.15). They have been

followed up on an outpatient basis for 6 months on average, with

some patients with up to 12 months of follow-up and 0 recurrences to

date.

Conclusion: This work presents the efficacy of the anterior compo-

nent separation technique in the treatment of large complex hernias.

P-1227

Improving post-operative outcomes for abdominal wall

reconstruction through an enhanced recovery protocol

Voigt C, Whitenack N, Vonk J, Collister P, Brown S,

Maloley-Lewis B, Mukkai Krishnamurty D, Fitzgibbons RCreighton University

Introduction: Enhanced recovery after surgery (ERAS) protocols

have shown efficacy in decreasing re-admissions, length of stay

(LOS), and post-operative complications. The effect of ERAS

protocols in improving post-operative outcomes in patients under-

going abdominal wall reconstruction (AWR) has not been studied. In

this study, we evaluated post-operative outcomes following imple-

mentation of a resident driven implementation of ERAS protocol in

patients undergoing AWR in a single institution.

Methods: A single surgeon (RJF) began implementation of the ERAS

protocol in 10/2017 in all patients undergoing AWR (N = 14) with

multimodal pain management (intra-thecal morphine, IV ketamine

and lidocaine, magnesium, ketorolac, IV and oral acetaminophen,

gabapentin and rescue oral narcotics), early ambulation, immuno-

nutrition, early post-operative diet, and removal of foley catheter on

POD 1. These patients were compared to a historical cohort of 23

patients from 4/2015 to 9/2017 who received a combination of

epidural and IV narcotics for pain management, and foley catheter in

place till epidural was discontinued. Charts were reviewed for

demographic information and outcomes including LOS, readmission,

and urinary retention. Data were analyzed with Student’s t-test and

Fisher’s exact test as appropriate. A linear regression model was used

to assess LOS, adjusting for age and sex. P value\ 0.05% was

considered significant.

Results: There was a significant difference in age (pre-ERAS

60 ± 14 years, post-ERAS 48 ± 16 years, p\ 0.01). There were no

significant difference in sex. There was a significant improvement in

LOS (pre-ERAS 5.7 ± 2.2 days, post-ERAS 4 ± 1 days, p\ 0.01).

There was no significant difference in readmission despite the earlier

discharge in the ERAS group. Post-operative urinary retention rates

were similar in both groups.

Conclusion: ERAS protocol after AWR resulted in a significant

decrease in LOS. This study, while limited by sample size, provides

evidence for the effectiveness of ERAS protocols in major AWR

surgery.

P-1228

Modified retromuscular Sugarbaker with transversus

abdominis release via enhanced-view totally

extraperitoneal (Etep) access: single-center experience

Addo A, Broda A, Estep A, Lu R, Zahiri R, Turcotte J,


Background: A variety of operative approaches have been described

to address parastomal hernias, a common complication of long-term

stomas. Accordingly, outcomes have varied due to this lack of stan-

dardized care. The current study sought to evaluate our outcomes post

enhanced-view totally extraperitoneal (eTEP) Sugarbaker technique

utilizing transversus abdominis release (TAR).

Method: A retrospective review of all patients who underwent eTEP

Sugarbaker parastomal hernia repair with TAR at Anne Arundel

Medical Center between December of 2015 and June of 2018 was

conducted. Demographic, intraoperative and postoperative outcomes

data were analyzed using univariate analysis.

Results: Ten patients were included in the final analysis. Laparo-

scopic (n = 1) and robotic (n = 9) were used for patients. 50% of

patients were male, mean BMI was 28.5 kg/m2 and median ASA class

was 3. Mean operative time was 264.1 min and mean total hospital

cost was 17,386 US dollars. The mean length of stay was 3.9 days

(range 1–10 days) and patients were followed after surgery for an

average of 11 months. There was no 30-day readmissions or reop-

erations. Four patients suffered from ileus, seroma or prolonged

urinary retention after surgery, all managed nonoperatively. There

was no incidence of recurrence, mesh infection or mesh erosion into

the bowel conduit during follow-up.

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Hernia (2019) 23 (Suppl 1):S50–S100 S92

Conclusion: The eTEP access Sugarbaker repair with TAR modifi-

cation, enables extraperitoneal dissection of wide restromuscular

space for mesh placement thus limiting implant exposure to intra-

abdominal viscera. This novel technique needs further long-term

follow-up but early results are promising.

P-1229

Use of complex abdominal reconstruction techniques

(CART) after exploratory laparotomy and open

abdomen (OA)

Kao A, Maloney S, Otero J, Prasad T, Lincourt A, Kasten

K, Colavita P, Heniford B, Augenstein VCarolinas Medical Center

Introduction: Open abdomen (OA), or temporary abdominal closure

with planned relaparotomy, can be a life-saving damage control

strategy for both trauma and non-trauma patients. Prolonged OA

therapy often leads to challenges with abdominal closure, however

long-term data on the prevention of incisional hernias in OA patients

is poorly understood. This study evaluates utility of CART for OA

patients.

Methods: An institutional (Premier) database was queried for non-

trauma patients requiring emergent laparotomy and OA at a tertiary

referral center (2012–2016). Use of CART included component

separation and prophylactic mesh placement.

Results: 203 patients (mean 62.4 ± 13.5 years) underwent laparo-

tomy with OA (average number of reoperations 1.6 ± 1.5; hours left

open 53.4 ± 83.0). 23 (11.3%) patients had CART, including 6

(3.0%) with component separation and 19 (9.4%) with mesh repairs.

Compared to patients without CART, those requiring component

separation/mesh had more operations after index laparotomy

(2.8 ± 2.1vs. 1.4 ± 1.4, p\ 0.0001) and prolonged OA time

(121.5 ± 103.9vs. 44.1 ± 75.5 h, p\ 0.0001). Types of component

separation included posterior approach (n = 4) and external oblique

release (n = 2). Among mesh repairs, biologic mesh was used in 12

(63.2%) patients and synthetic mesh in 7 (36.8%). Mesh was placed

retrorectus in 11 (57.9%), as an onlay in 4 (21.1%), and 4 (21.1%) as a

bridge. Of OA patients surviving to closure, 29.3% developed an

incisional hernia, 3.9% had fascial dehiscence, and 2.0% had ente-

rocutaneous fistula after a mean follow-up of 13.0 ± 16.0 months.

After excluding bridged repairs, rates of hernia (36.8% vs. 26.8%) and

fascial dehiscence (8.7% vs. 4.7%) were similar between CART and

no CART (p[ 0.05).

Conclusions: Primary fascial closure after OA management can be

technically challenging, particularly in patients with multiple reop-

erations and prolonged time before attempted closure. Use of CART,

such as component separation and prophylactic mesh, may lower rates

of wound dehiscence and subsequent hernias. Additional large studies

are needed to further evaluate the impact of CART, however in this

patient population with excess tension on OA closure, consideration

may be given to preoperative tension-reducing strategies such as

rapid-acting neurotoxin.

P-1234

Feasibility of robotic-assisted retromuscular ventral

hernia repair as an outpatient procedure

Lundberg J, Lee B, Peterson E, Gagliano R, Weinberg J,

Gillespie TSt Joseph’s Hospital and Medical Center

Open posterior component separation of the rectus muscle with

placement of inlay mesh is the standard by which all midline

abdominal wall hernia repairs should be measured. Robotic tech-

niques for this procedure have reduced patients’ length of stay (LOS).

A relatively novel application of this technique is the unidock robotic

retromuscular ventral hernia repair (ur-RVHR), which only uses three

ports and putatively reduces postoperative pain. Enhanced recovery

pathways after surgery (ERAS) have also helped decrease LOS.

Transverse abdominis plane (TAP) blocks improve pain control over

standard regimens. Innovative techniques of mesh fixation avoid

trans-abdominal fixation sutures and consequent morbidity. In

aggregate, these advancements have developed with a view toward

decrease healthcare costs and optimizing patient outcomes. We pre-

sent a clinical pathway for repair of midline abdominal wall hernias

that used an ERAS protocol, TAP block, and ur-RVHR technique

with placement of self-adherent mesh. We hypothesized our clinical

pathway would decrease LOS compared to published norms.

A single surgeon’s series of 11 patients undergoing elective three

port ur-RVHR were analyzed. All patients followed the ERAS pro-

tocol and underwent a preoperative TAP block. Self-adherent

polyester mesh was used without supplemental fixation strategies.

Length of stay was measured.

Median LOS for was 22 h and 57 min. 8 of 11 patients were

discharged within 24 h and qualified for outpatient status. All other

patients were discharged in less than 2 days. The greatest LOS was

37 h and 52 min. Average operating time was 240 min. There were

no 30 day readmissions or surgical site infections.

The median LOS using our pathway was less than 23 h and

compares favorably to the previously reported LOS r-RHVR of

2 days by the American Hernia Society Quality Collaborative. The

long-term effect of our pathway requires further study.

P-1238

Abdominal wall reconstruction with large

polypropylene mesh: is bigger better?

Hughes T, Buckley T, Plymale M, Davenport D, Roth JUniversity of Kentucky

Background: Abdominal wall reconstruction (AWR) techniques

continue to evolve in an effort to improve outcomes. Previously, large

meshes were created in the operating room by suturing multiple

meshes (MM). With the availability of large polypropylene mesh up

to 50 9 50 cm (LM), AWR may be accomplished with a single mesh.

This study evaluates clinical and economic outcomes following AWR

with component separation utilizing MM and LM.

Methods: A retrospective study of patients undergoing AWR

between was performed with review of health records and cost

accounting data. Patients that underwent AWR with LM were iden-

tified and case matched 1:1 with patients undergoing MM repair

based upon comorbidities, defect size and wound class. Clinical and

economic data were evaluated.

Results: 24 patients underwent AWR with LM. 20 patients (10F,

10 M) who underwent AWR with LM were matched with 20 MM

AWR (11F, 9 M). Age, BMI, ASA 3 ?, never smoker, diabetes, and

COPD were similar. Hernia characteristics including incidence of

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S93 Hernia (2019) 23 (Suppl 1):S50–S100

recurrent repair, incidence of prior mesh infection, CDC wound class,

defect size, mesh size were similar between LM and MM.

Operative cost ($4295 vs. $3669, p = 0.127), operative time (259 min

vs 243 min, p = 0.817), blood loss (230 ml vs 230 ml, p = 0.995),

length of stay (5.5 vs 6.2, p = 0.484), wound complication (30% vs

20%, p = 0.716), infected seroma (5% vs 5%, p = 1.000), non-wound

complication (15% vs 30%, p = 0.451) and readmission (5% vs 15%,

p = 0.605) were similar between LM and MM respectively.

Conclusions/Recommendations: This is the first report of patients

undergoing AWR with a large 50 9 50 cm polypropylene mesh. In

this small cohort, clinical outcomes were similar between those

undergoing repair with multiple sutured mesh sheets and a single

large mesh. Further prospective studies with long-term follow up are

required to appreciate the clinical and economic impacts of AWR

with large mesh.

P-1239

(Ballon) Comparison between balloon and telescopic

dissection in fully extraperitoneal laparoscopic inguinal

repair (PET): partial results from a randomized

controlled prospective study

Zanirati T, Cavazzola L, Araujo T, Wolkweiss BHospital de Clınicas de Porto Alegre

Laparoscopic repair is technically challenging. Comparing TEP and

TAPP, we identified relative advantages of TEP as no peritoneal

violation, less risk of hernia in the portal or opening of the parietal

peritoneum, lower risk of intraperitoneal visceral lesions. We devel-

oped this project to investigate if the use of a balloon trocar device

would reduce the surgical time for the preperitoneal space dissection

in TEP in relation to the dissection performed only with the use of

laparoscopic optics. Randomized, controlled clinical trial with a

sample of 26 patients, 13 in each group.

Results: 5 EHS I and 9 EHS II were found in the telescopic group 4

EHS I, 4 EHS II and 2 EHS III. In three cases there were problems

with the trocar or with the balloon, occurring leakage in two and

rupture of the balloon in another. Three patients presented seroma,

with improvement after drainage, two of the balloon group and one of

the telescopic group. Dissection time was 75.4 min (telescopical) vs

54 (balloon) P = 0.124, total surgical time 89.6 vs 85.2 P = 0.759.

Conclusion: The balloon trocater dissection method is safe and has

the same rate of recurrence in the literature and with a tendency to

reduce surgical time.

P-1240

Multiple, recurrent, infectious hernia repair

in the complicated obese patient

Richards J, Gillespie T, Huang DCreighton University and Medical Center at St. Joseph Hospital

and Medical Center

A 43-year-old female with BMI of 32 and a past surgical history of

sleeve gastrectomy, wound infection, multiple ventral hernia repairs

and previous mesh explantation presented with two symptomatic

recurrent abdominal wall hernias. The patient’s most recent recur-

rence was repaired with onlay absorbable mesh. Another piece of

previously implanted synthetic mesh remained in her upper abdomen

with a superior hernia as well as a second hernia lateral to the midline.

The lateral hernia defect was 10.2 cm. Her rectus muscles were

attenuated and narrow. She had a large diastasis of the midline. She

had a history of chronic panniculitis and was evaluated by plastic

surgery.

During surgery all previous mesh was explanted. She underwent a

bilateral posterior component separation with posterior transversals

release. A 40 9 25 cm piece of perforated biological mesh was fix-

ated in in the retromuscular space. Fascial closure was tension free.

Plastic surgery performed a lateral abdominoplasty. Multiple drains

were placed. There were no immediate complications.

22 days later she presented with abdominal pain, erythema, and

edema of the incision. CT scan showed a subcutaneous collection.

She also had intra abdominal fluid collections above and below the

mesh. She underwent operative incision and drainage of the superfi-

cial fluid collection. A wound vacuum assist device ultimately was

applied. Interventional radiology placed intra abdominal drains.

Cultures grew Cutibacterium. She was placed on antibiotics. She

improved and was discharged with two intra abdominal drains. Fol-

low up CT 2 weeks later showed recurrent fluid collection away from

the two other previous drain sites. A third drain was placed by

interventional radiology.

Currently there is no recurrence of the hernia. It is unclear if this

mesh infection can be treated with drains and antibiotics. She is being

considered for mesh explantation.

P-1243

Initial experience in Etep Rives-Stoppa in a University

Hospital in Chile


Jarufe N, Pimentel FPontificia Universidad Catolica de Chile

Background: Minimally invasive hernia repair provides faster

recovery and less infections. The eTEP Rives-Stoppa (eTEP RS) is an

excellent minimally invasive technique for ventral hernia repair with

a sublay mesh position but it has been associated with a long learning

curve.

Objective: To report our initial experience and short term outcomes

with eTEP RS for the minimally invasive management of ventral

hernias in a University hospital in Chile.

Methods: Retrospective case series of the first 26 patients with

ventral hernias who underwent a minimally invasive abdominal wall

reconstruction with an eTEP RS approach between December 2016

and September 2018. Demographic, perioperative data and early

outcomes were included for analysis.

Results: During the study period 26 patients underwent a eTEP RS

abdominal wall reconstruction. Average age was 55 years old (range

38–77), 65% were man, 20 patients were ASA II and the rest were

ASA I. All patients had a midline defect with a maximum defect

width of 8 cm (range 1–8), 14 patients had multiple midline defects.

All patients underwent a complete preoperative evaluation and were

asked to lose weight before surgery and all patients achieved midline

closure. Average operative time was 120 min (range 60–200) and was

lower throughout the learning curve. Patients with inguinal hernias

and diastasis recti were also managed in the same laparoscopic pro-

cedure. Two patients underwent a Hybrid approach for the

management of large hernia sacs. The average mesh size used was

500 cm2 (range 100–720).

One patient had a reoperation for the drainage of a hematoma,

explored with a laparoscopic approach. There was no mortality in this

initial series. No surgical sites infection were identified in this initial

case series.

Conclusion: eTEP RS is a complex procedure but it has a safe

learning curve with promising results similar to those reported in the

literature.

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Hernia (2019) 23 (Suppl 1):S50–S100 S94

P-1245

Mesh removal and tailored neurectomy for treatment

of chronic postoperative inguinal pain: a single center

experience

Tastaldi L, Krpata D, Prabhu A, Fafaj A, Alkhatib H,

Svestka M, Rosenblatt S, Rosen MCleveland Clinic

Background: Chronic postoperative groin pain (CPIP) is a chal-

lenging long-term complication after inguinal hernia repair. We aim

to evaluate our institutional experience with the surgical treatment of

CPIP.

Methods: All patients who underwent surgical treatment of CPIP at

our institution from August 2014 through February 2017 were iden-

tified. A retrospective review of electronic medical records and

telephone interviews were performed to complement database infor-

mation. Measured outcomes included reduction in pain scores and

patient satisfaction at final follow-up.

Results: 15 consecutive patients operated at our institution responded

to a telephone interview. Mean age was 44 years, and 67% were male.

Prior meshes were removed along with mesh fixation in all cases. Ten

patients (67%) had a neurectomy performed, being 6 selective and 4

triple neurectomies. Mean baseline pain score was 7.66 (SD2, range

4–10). At a mean follow-up of 14 months, a significant reduction in

pain scores was seen (mean 3.26, SD 3.44, p\ 0.002, 95% CI

2.52–6.27). Ten patients (67%) had improvement in their symptoms

and would recommend surgical management for a friend with CPIP,

and 8 (53%) patients reported being ‘‘pain-free’’ or ‘‘almost pain-

free.’’ Seven patients (47%) are still affected by pain and with QoL

impairment despite some degree of pain reduction.

Conclusions: CPIP is a complex problem with multiple factors that

influence operative management. Our approach of mesh removal with

tailored neurectomy conferred CPIP resolution in over half of the

patients in this cohort. Careful patient selection and pre-operative

counseling to define expectations should be performed surgical

treatment for CPIP.

P-1248

An evaluation of fascial closure techniques in open

ventral hernia repair: practice patterns and short-term

outcomes

Tenzel P, Bilezikian J, Israel I, Appleby P, Hope WNew Hanover Regional Medical Center

The best method for fascial closure during hernia repair remains

unknown. This study evaluates the impact of fascial closure tech-

niques on short-term outcomes.

All patients undergoing open ventral hernia repair were queried

using the Americas Hernia Society Quality Collaborative (AHSQC)

database. Analysis was stratified by suture type (absorbable, perma-

nent) and technique (figure-of-eight, running, interrupted). Outcome

measures included Surgical Site Infection (SSI), Surgical Site

Occurrence (SSO), SSO requiring intervention (SSOPI), recurrence

rate, and quality of life. Descriptive statistics and logistic regression

were performed.

6544 patients were included. Two-thirds of surgeons closed fascia

during ventral hernia repair with absorbable suture, and 1/3 with

permanent suture. In the absorbable group, 17% used figure-of-eight,

46% running, and 4% interrupted suture. In the permanent group,

13% used figure-of-eight, 8% running, and 11% interrupted suture.

There was no significant association between SSO and closure

technique (p = 0.2). However, SSO and suture type was significant

(p\ 0.001) with the odds of SSO for closure with absorbable suture

being 61.7% higher than the odds of permanent. Fascial closure

technique and suture type had no significant association (p[ 0.5)

with SSI, SSOPI, hernia recurrence rate, or HerQLes or NIH promis

3a scores at 30 days or 6 months.

Fascial closure technique and suture material do not have a major

impact on outcomes in ventral hernia repair. Despite a significantly

higher rate of SSO for absorbable sutures compared to permanent, this

did not increase the rate of interventions.

P-1251

How does contamination impact outcomes in abdominal

wall reconstruction?

Lewis R, Ramshaw B, Forman BUniversity of Tennessee Medical Center-Knoxville

Introduction: The use of hernia mesh is a common practice in

abdominal wall reconstruction (AWR) operations. Many AWR

operations are performed in the setting of chronically and/or acutely

infected and contaminated surgical fields.

Methods: A single hernia program implemented the principles of

clinical quality improvement (CQI) in an attempt to improve out-

comes for hernia patients. A resorbable synthetic hernia mesh was

used in place of a variety of biologic meshes for patients undergoing

AWR in either contaminated or non-contaminated surgical fields as

an attempt to improve the care process.

Results: Ninety-two patients who underwent AWR were included

over an 48-month time interval (08/2011 to 08/2015), of which 62 did

not have pre-operative or intra-operative sings of active infec-

tion/contamination (non-contaminated) and 30 did have clinical signs

of active infection (contaminated). In the non-contaminated group,

there were four surgical site occurrence (SSO) (6%) and five surgical

site infections (SSI) (8%), for a total wound complication rate of 14%.

In the contaminated group, there were 10 SSOs (33%) and seven SSIs

(23%), for a total wound complication rate of 57%. Despite the rate of

wound complications, most were minor, required little or no treatment

and were resolved within 2 months. In both contaminated and non-

contaminated groups, there were no mesh related complications and

no mesh removal (partial or total) was required.

Conclusion: In this group of AWR patients, the use of resorbable

synthetic mesh in place of a variety of biologic meshes was imple-

mented in a process for quality improvement. Value improvement for

patients was demonstrated by the lack of mesh-related complications,

including removals, and decrease in mesh costs compared with bio-

logic options.

P-1253

Laparoscopic treatment of incarcerated

and strangulated groin hernias: a preliminary

experience

Bilezikian J, Appleby P, Israel I, Tenzel P, Eckhauser F,

Hope WNew Hanover Regional Medical Center

Groin hernia repair is one of the most commonly performed surgical

procedures in the United States, with a reported strangulation risk

of\ 1% per year. Risk factors for strangulation include older age, co-

morbidities including ASA stage, and late presentation/hospitaliza-

tion. Traditional surgical management has employed an open

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S95 Hernia (2019) 23 (Suppl 1):S50–S100

approach through single or multiple incisions. The advent of laparo-

scopic surgery offers a minimally invasive alternative, but experience

to date has been limited.

We report our preliminary experience with eight patients who

underwent laparoscopic repair of incarcerated or strangulated groin

hernias at a single institution between 2013 and 2018. Demographics,

perioperative and short-term outcomes were reviewed, and descrip-

tive analysis was performed.

Our series consisted of seven women and one man with an average

age of 80.4 years (range 62–92 years). There were six femoral hernias

and two inguinal hernias. Two patients underwent manual hernia

reduction in the ED and urgent repair within 24 h; the remaining six

patients (75%) underwent emergent surgical intervention. All patients

underwent small bowel resection through a small para-umbilical

incision and TAPP repair using Bard 3DMax light mesh. Four

patients developed complications (50%), including ileus in three

patients, one of whom developed a pelvic abscess that did not require

operative intervention, and C. difficile colitis in one patient. Average

length of stay (ALOS) for the entire group was 7 days but increased

nearly three-fold in patients with complications (10.1 days versus

3.7 days, respectively). Five patients (62.5%) were available for

30-day follow-up with no hospital readmissions, mesh-related com-

plications or evidence of recurrence.

The results of this study suggest that laparoscopic repair of

incarcerated or strangulated groin hernias may be a feasible alterna-

tive to the more conventional open approach. Additional randomized

controlled studies are needed to confirm efficacy and safety and

identify patients who would benefit most from this approach.

P-1254

The intersection of gender, ventral hernia repair,

and abdominal wall quality of life

Bernardi K, Bernardi K, Olavarria O, Lyons N, Milton A,

Holihan J, Kao L, Ko T, Liang MUniversity of Texas He

Introduction: Ventral hernias drastically affect a patient’s abdominal

wall quality of life (AW-QOL). Previous studies showed that women

without ventral hernias have a lower mean baseline AW-QOL by 7%

compared to men. Also, other studies suggested that women may have

worse outcomes after surgery. The aim of this study was to determine

the effects of gender in AW-QOL after ventral hernia repair (VHR).

Methods: Patients from a specialty hernia clinic at a single safety-net

academic institution eligible for VHR were enrolled. All patients

completed a validated, hernia-specific, modified activity assessment

scale (mAAS) survey before surgery and 2 years after VHR. On this

scale, 1 is poor QoL, 80 is normal, and 100 is perfect; a change of 7 is

the minimum clinically important difference. Primary outcome was

the patient factors independently correlated with AWL-QOL; these

were identified using multivariable analysis. Secondary outcomes

included the difference in baseline, post-operative, and the change in

QOL scores were compared by gender using t-test.

Results: A total of 276 patients scheduled for a ventral hernia repair

were enrolled, 67% were females. The average baseline AW-QOL

score was lower in women when compared to men (32.5 ± 3.2 versus

40.1 ± 2.1, p = 0.041). At 2 year follow up, the scores were equiv-

alent for both gender groups (66.6 ± 2.3 versus 66.7 ± 3.1,

p = 1.00); however, improvement in AW-QOL score was higher in

females compared to males (34.1 ± 2.6 versus 26.6 ± 3.0,

p = 0.051). On multivariable analysis multiple factors were identified

as influencing change in AW-QOL, including, age (0.23), body mass

index (BMI) (- 3.12), gender (15.14), hernia type (incisional 11.16),

and hernia area on CT-scan (0.39).

Conclusion: Although women with a ventral hernia have lower AW-

QOL score at baseline, they experience a greater improvement in their

AW-QOL after VHR. Despite former studies showing that women

may experience worse outcomes after VHR differences in baseline

AW-QOL may not have been accounted for.

P-1255

Prevalence of hernias among patients undergoing

computed tomography and their impact on quality

of life

Olavarria O, Bernardi K, Milton A, Lyons N, Shah P, Ko T,

Kao L, Liang MMcGovern Medical School at UTHealth

Introduction: With the growing obesity epidemic and widespread use

of advanced imaging there is a need to quantify the prevalence and

impact of hernias. Our aim was to determine the prevalence of

abdominal wall hernias among patients undergoing CT scans and

their impact on abdominal wall quality of life (AW-QOL).

Methods: Consecutive patients undergoing elective CT abdomen/

pelvis scans were enrolled. History and standardized physical exam-

ination were performed. AW-QOL was measured through the

modified Activities Assessment Scale, a validated, hernia-specific

survey. On this scale, 1 is poor AW-QOL, 100 is perfect and a change

of 7 is the minimum clinically important difference. CT scans were

reviewed for the presence of ventral or groin hernias. The number of

patients and their AW-QOL scores were determined for four groups:

no hernia, clinical or radiographic hernias, clinically apparent hernias,

and hernias only seen on radiographic imaging (occult hernias).

Results: A total of 246 patients were enrolled of whom 76 (30.8%)

were overweight and 105 (42.6%) were obese. Physical examination

detected a ventral hernia in 50 (20.3%) patients and a groin hernia in

17 (6.9%) patients while CT scan revealed 128 (52.0%) and 64

(26.0%) respectively. Of patients with a hernia on CT scan, 85

(34.5%) had an occult ventral hernia and 40 (16.2%) had an occult

groin hernia. The AW-QOL, median (IQR), of patients with no hernia

was 84 (46), while the AW-QOL of those with a clinical hernia was

62 (55) and 77 (57) among those with an occult hernia.

Discussion: One-fourth of individuals undergoing CT abdomen/pelvis

scans have a clinical hernia while over 40% have an occult hernia.

Compared to individuals with no hernias, patients with clinically

apparent or occult hernias have a significantly lower median AW-

QOL (by 22 and 7 points respectively). Randomized trials are needed

to determine if operative repair improves AW-QOL.

P-1256

The role of biosynthetic mesh in abdominal wall hernia

repair in the setting of obesity, recurrence and high risk

patients

Lighter M, Roberts JSt. Mary Mercy Livonia

Background: The repair of abdominal wall hernias pose a difficult

problem for surgeons in the presence of obesity, recurrent hernias and

high risk patient characteristics.

Methods: A retrospective review of 22 patients who underwent

abdominal wall hernia repair with a biosynthetic GORE SYNECOR

Biomaterial hybrid mesh by a single surgeon at a single institution,

between 2016 and 2018. Indications for use included the following

pre-operative patient characteristics, which posed risks for potential

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Hernia (2019) 23 (Suppl 1):S50–S100 S96

complications: a BMI[ 40; chronic recurrent hernia and hernia

repair requiring panniculectomy. Types of procedures performed

include laparoscopic, robotic and open repairs with underlay, onlay or

retromuscular mesh placement with or without myofascial release,

with or without panniculectomy. Patients were followed up post-op-

eratively at 2 weeks and at 30 days.

Results: Of the 11 patients who had primary hernia repairs, three

underwent a laparoscopic procedure with underlay mesh placement.

Seven patients had an open procedure, six with retromuscular mesh

placement with myofascial release, and one with an onlay mesh, four

panniculectomies. One patient underwent a robotic repair with

underlay mesh with a recurrent hernia reported at 30 day follow-up.

Of the 11 patients who underwent repair for a recurrent hernia, two

had a laparoscopic procedures with underlay mesh. Nine had an open

procedure, two with onlay mesh, one of which developed a post-

operative seroma, one with underlay mesh placement, six with

retromuscular mesh placement who underwent a myofascial release,

four with panniculectomy.

Conclusion: Biosynthetic hybrid mesh (GORE SYNECOR Bioma-

terial) is an alternative in complex cases where pure biologic mesh

has been traditionally utilized, such as in the presence of obesity,

multiple co-morbidities, recurrent hernias and high risk patients. Our

early data demonstrates acceptable outcomes in complex cases

specific to recurrence rates and postoperative morbidity and mortality.

Keywords: Abdominal wall hernia, Biosynthetic Hybrid mesh.

P-1257

Patient related factors that affect abdominal wall

quality of life

Olavarria O, Bernardi K, Milton A, Lyons N, Shah P, Ko T,

Kao L, Liang MMcGovern Medical School at UTHealth

Introduction: It has been shown that ventral and groin hernias affect

patient abdominal wall quality of life (AW-QOL). However, it is

unknown what other factors can alter patient AW-QOL. We sought to

identify factors independently associated with AW-QOL among

patients undergoing computed tomography (CT) scans of abdomen/

pelvis.

Methods: Patients undergoing elective CT scans of abdomen/pelvis

were enrolled. In general, CT scans were performed with oral and

intravenous contrast with 5 mm cuts. History and standardized

physical examination were performed by a surgeon blinded to the CT

scan results. CT scans were reviewed for the presence of ventral and

groin hernias by three surgeons blinded to the results of the physical

examination. AW-QOL was measured through the modified Activities

Assessment Scale, a validated, hernia-specific survey. On this scale, 1

is poor QoL, 80 is normal, and 100 is perfect; a change of 7 is the

minimum clinically important difference. Primary outcome was

patient related factors associated with poor AW-QoL. Multivariable

linear regression was performed to identify these variables.

Results: A total of 489 patients were enrolled, of which 290 (59.3%)

had a ventral hernia, 126 (25.8%) had an inguinal hernia, and 144

(29.4%) had no hernia. On univariate analysis, differences in QOL

were affected by the following: obesity (BMI[ 30 kg/m2), current

smoker status, presence of an ostomy, previous abdominal surgery,

previous ventral hernia repair, ventral hernia on exam, and hernia

size. On multivariable analysis, female sex (- 6.2), obesity (- 7.3),

presence of an ostomy (-11.9), previous VHR (-15.6), and hernia on

CT (- 6.7) were independently associated with poor AW-QOL.

Discussion: Multiple factors affect patients AW-QOL, not just her-

nias. The factors with the largest negative impact on AW-QOL are

iatrogenic: prior ventral hernia repair or creation of an ostomy. With

increasing focus on patient QOL, more research is needed to under-

stand AW-QOL among patients with and without hernias.

P-1258

Primary thoracoabdominal hernia repair: a challenging

trifecta of abdominal wall, chest wall and diaphragm

herniation

Alayon-Rosario M, Griscom T, Warren J, Carbonell A,

Cobb WGreenville Health System

Primary thoracoabdominal hernias are a rare event involving the tri-

fecta of abdominal wall hernia, chest wall defect, and diaphragm

hernia. We report our experience with repair of this rare entity. A

retrospective analysis of thoracoabdominal hernia repairs between

July 2010 through July 2017 was performed. Data included demo-

graphics, inciting events, operative findings and repair technique, and

outcomes. Recurrence, surgical site occurrences and medical com-

plications were recorded. Six patients were identified with

thoracoabdominal hernias. All were male, five were current or former

smokers, and four with diagnosis of chronic obstructive pulmonary

disease. All hernias resulted from an episode of violent coughing.

Repair was performed in open fashion in five patients, and robotically

in one. Mesh reinforcement for ventral hernia was used in four

patients, and rib plating with wire fixation of involved ribs was used

in three. No intraoperative complications occurred. There were two

chest wall recurrences (33%) and two ventral hernia wall recurrences

(33%) that both were re-repaired with suture and lap mesh, respec-

tively. The two chest wall recurrences were originally repaired by

suture reapproximation of the ribs alone. No chest wall recurrences

developed in patients closed with plating and wire fixation. No

recurrent diaphragm defects reported. Surgical site infection occurred

in one patient (16%). Primary thoracoabdominal hernias pose a real

challenge to the hernia surgeon. An open approach with step-wise

reconstruction provides a durable result. We recommend rib plating

and wire closure, as well as mesh reinforcement of abdominal wall.

P-1259

An evaluation of ventral hernia repair with a new

prosthetic mesh

Bilezikian J, Israel I, Appleby P, Tenzel P, Hope WNew Hanover Regional Medical Center

Mesh is generally recommended for repair of ventral and incisional

hernias. There are many types of mesh that can be used for hernia

repair including permanent synthetic meshes, absorbable synthetic

meshes, and biologic meshes. Synecor is a new permanent synthetic

mesh made of a combination of absorbable synthetic component and a

permanent synthetic component that can be used intraperitoneally or

within the layers of the abdominal wall. There is little data concerning

outcomes related to this new mesh product. The purpose of this

project is to review our outcomes using Synecor mesh in ventral

hernia repair.

A retrospective review of all patients undergoing ventral hernia

repair using Synecor mesh was performed using the Americas Hernia

Society Quality Collaborative (AHSQC) database from 4/2016 to

9/2018. Demographic, perioperative, and short-term outcomes (SSI,

SSO, SSOPI) were reviewed and descriptive statistics were

performed.

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S97 Hernia (2019) 23 (Suppl 1):S50–S100

There were 31 patients who underwent ventral hernia repairs using

Synecor mesh. Average age was 58 (range 29–78) with 45% male and

87% Caucasian. 94% of cases were clean cases. Comorbidities were

found in 68% of patients. Open repairs were performed in 39% of

cases and included a retrorectus repair in 67% and TAR in 75% of

open cases. Laparoscopic repairs were performed in 42% of cases and

robotic in 19% with 78% having closure of defect during repair. At

30 day follow up, the rate of SSI was 3%, SSO was 6% and SSOPI

was 3%. There were 16% complications and recurrence rate was 6%

at an average follow up of 115 days (range 30 days–1 year).

Synecor mesh represents a new synthetic mesh that may be used

for ventral hernia repair in either an open, laparoscopic, or robotic

fashion. Short-term, preliminary results appear favorable but more

study is needed to be able to fully evaluate this new mesh prosthetic.

P-1262

Pancreatic adenocarcinoma with pancreatic pseudocyst

within diaphragmatic hernia

Israel I, Tenzel P, Bilezikian J, Hope W, Fillion MNew Hanover Regional Medical Center

A 64-year-old Caucasian male presented to the ED with abdominal

pain for 4 days. He denied nausea, vomiting, diarrhea, fevers or chills.

He had no significant past medical history and his only surgery was a

tonsillectomy. Work up in the emergency department revealed pan-

creatitis likely secondary to gallstones. He was discharged and

underwent an elective and uneventful laparoscopic cholecystectomy

with negative intraoperative cholangiogram 8 weeks later.

10 weeks postoperatively, he presented to his primary care

physician for reflux type symptoms, abdominal fullness, and nausea.

An abdominal ultrasound was ordered concerning for a

15 9 15 9 10 cm loculated pancreatic pseudocyst, therefore he was

referred to gastroenterology for an EUS. EUS revealed 13 mm

hypoechoic mass within the midbody of the pancreas. The pseudocyst

was thought to be a sequalea of gallstone pancreatitis but after EUS

confirming mid body mass with distal pancreatic duct dilation, it was

likely this was actually due to the pancreatic adenocarcinoma. 3 days

after his clinic visit, he presented to the ED for increasing nausea and

inability to tolerate any oral intake. CT scan revealed 10x8 cm pan-

creatic pseudocyst extending into the esophageal hiatus.

He was taken to the operating room for resection of pancreatic

adenocarcinoma and pseudocyst. The crura were identified and the

pseudocyst wall was noted to be densely adherent to the aorta. The

risk of detrimental injury to the aorta was thought to outweigh the

benefit of repairing the defect. We decided to resect what pseduocyst

we could and drain this area. A 10 Fr Jackson-Pratt drain was placed

in the thorax between the crura to drain the residual pseudocyst and

another 10 Fr Jackson-Pratt drain was placed overlying the pancreatic

neck.

Post operatively he had a fascial abscess requiring drainage but

otherwise did well. He started gaining weight and had no additional

diaphragmatic hernia symptoms.

P-1263

Validating the ventral hernia recurrence inventory

(VHRI) In hernia widths ‡ 10 cm

Alkhatib H, Luciano T, Fafaj A, Svestka M, Petro C,

Krpata D, Prabhu A, Poulose B, Rosen MCleveland Clinic Foundation

Introduction: The Ventral Hernia Recurrence Inventory (VHRI) has

been validated before in a cohort of patients with a mean hernia width

of 6 ± 4.5 cm. Hernia defects C 10 cm have different anatomic

diruptions, with different contour outcomes after surgery, which may

affect the validity of the VHRI.

Methods: The Americas Hernia Society Quality Collaborative

(AHSQC) registry was quired for all patients with hernia widths

C 10 cm who underwent open ventral hernia repair with at least

1 year response to the VHRI, and a CT scan or ultrasound recorded in

the same period. Sensitivity, specificity, negative predictive value,

and positive predictive value were calculated for each question in the

VHRI.

Results: The sensitivity and specificity for ‘‘Do you feel or see a

bulge?’’ was found to be 70% [95% CI 51%–88%) and 81% [77%–

87%], respectively. The negative predictive value was found to be

94% [CI 91%–100%]. The same question combined with ‘‘Do you

feel your hernia has come back?’’ did not result in improved sensi-

tivity or specificity.

Conclusion: As hernia width increases, the validity of the VHRI

decreases. However, answering ‘‘No’’ to ‘‘Do you feel or see a

bulge?’’ continues to be a good marker for absence of a hernia

recurrence.

P-1264

Hernia occurrence after prophylactic mesh placement:

a single institution retrospective review

Israel I, Tenzel P, Bilezikian J, Appleby P, Hope WNew Hanover Regional Medical Center

Prophylactic mesh use has decreased rate of incisional hernias

specifically in stoma creations and open aortic surgery. The purpose

of this study was to evaluate complications and hernia occurrence

rates in patients who underwent prophylactic mesh augmentation

between 2016 and 2018 in single institution.

A retrospective review was performed of 30 patients who under-

went prophylactic mesh augmentation for ostomy creation or aortic

surgery between June 2016 and August 2018. All patients had pro-

phylactic mesh augmentation in either the retrorectus or preperitoneal

space. Six of the patients underwent prophylactic mesh augmentation

for prevention of incisional hernia. The other 24 patients underwent

prophylactic mesh placement for prevention of parastomal hernia

occurrence. Three patients were lost to follow up and two have future

follow up appointments scheduled. The rest of the 25 patients were

followed for hernia occurrence and other complications. Follow up

was defined as either imaging or physical exam after discharge from

original post operative hospital stay.

2 of the 30 patients (7%) suffered complications from the mesh

placement. One patient (3.5%) suffered a significant abdominal

wound infection requiring partial explant of mesh. One patient (3.5%)

had a large seroma collection. Of the 25 patients (83%) with follow

up, there have been no recurrences noted at an average follow up of

147.2 days (range 18–730).

Prophylactic mesh augmentation has demonstrated some promis-

ing results in decreasing hernia occurrences in the group of studied

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Hernia (2019) 23 (Suppl 1):S50–S100 S98

patients. Further study is needed to evaluate long term efficacy and

safety of this use of mesh.

P-1266

Reeves–Stoppa repair in the setting of chylous ascites

Christensen A, Bock S, Miller HUniversity of New Mexico

Background: Chylous ascites (CA) is a rare form of ascites based on

distinct fluid characteristics including a milky appearance and a

triglyceride level of[ 200 mg/dL. Malignancy and cirrhosis account

for approximately two-thirds of all CA cases in western countries.

Other etiologies include traumatic, congenital, infectious, neoplastic,

postoperative, cirrhotic, and cardiogenic. The management of CA

consists of identifying and treating the underlying disease process,

dietary modification, and diuretics. If medical management fails,

surgical exploration and ligation of the lymphatic duct may be

necessary.

Case presentation: We present a 53-year-old female with a history of

a right peri-nephric lymphangioma resection complicated by lym-

phatic leak, followed 12 years later by a total abdominal hysterectomy

complicated by fascial dehiscence. This then resulted in a moderate

sized ventral hernia. Standard medical management failed to control

her lymphatic leak. Over the next 3 years, she required several trips to

the emergency department for incarceration of her incisional hernia as

well as one hospitalization for gallstone pancreatitis. To correct her

incisional hernia, an elective Reeves-Stoppa repair was specifically

chosen in the setting of her CA to be completed concurrently with

cholecystectomy and repair of the lymphatic leak. Due to dense

adhesions, we were unable to isolate the lymphatic duct, therefore a

large volume of Fibrillar and Tisseel was applied over the area of the

leak. After a difficult dissection, a retro-rectus, preperitoneal mesh

repair was completed without complication. 1 year later the patient

has no evidence of hernia recurrence or ascites on follow up CT

imaging.

Conclusions: We present a 53 y/o female with a history of gallstone

pancreatitis, chylous ascites, and a symptomatic ventral incisional

hernia for which a single stage open cholecystectomy, the use of

hemostatic agents for her chyle leak, and a Reeves-Stoppa repair were

successful.

P-1268

Incisional hernia. Experience at a university center

Rappoport J, Martinez G, Dominguez C, Silva J, Carrasco

J, Jauregui C, Sanguineti A, Castillo CClinic Hospital, University of Chile

Aim: The AIM of the present study is to report the experience in the

treatment of incisional Hernia (IH), at our universitary center.

Methods: 672 patients, with IH, were attended at the Clinic Hospital,

University of Chile, between 2012 and 2016. Prospectively records of

demography, comorbidities, elective or emergency surgery, primary

surgery, type of herniorraphy performed and mesh employed, and

post operatory (30 days), morbimortality were analyzed. Stadistic

analysis: Chi square.

Results: Demography: 72% female and 28% male. 57% below

65 years. BMI mean 27 kg/m2. Comorbidities: Hypertension 43%,

Diabetes 15%, Hypothyroidism 6%, CPO 2.3%. Primary surgery:

biliary 24%, gynecologic 15%, coloproctological 12%, gastric 11%,

exploratory laparotomy 5%. Emergency surgery 5%, elective 92%

repair: without mesh 3%, with mesh: 86% Onlay, 7% Sublay, 2%

Inlay and 2% Intraperitoneal. Polypropylene mesh in 85%. Postop-

erative morbidities: wall hematoma 1%, enterotomy 2%, (recognized

and repaired at the same surgery), and enterocutaneous fistulae 0.1%.

97% of the patients did not present any morbidity; the present series

did NOT presented mortality. Routine use of subcutaneous drain and

abdominal elastic belt. Mean hospital stay: 3 days.

Discussion: Elective surgery, limited to BMI below 32, drastically

reduced post operatory morbidity. Onlay technic, showed excellent

results.

P-1270

Offering minimally invasive surgery in low resources

scenarios: early experience in brazil eTEP access

Grossi J, Grossi J, Santos, Azevedo, Paim D, Claus C,

CavazzolaSao lucas Hospital

Background: The advances in hernia surgery shows the most sur-

geons adopted the laparoscopic approach for treatment of ventral

hernia, because they have a less of hospital stay, surgical site infection

and faster recovery. One way to repair laparoscopic is enhanced-view

totally extraperitoneal (eTEP) with association the better repair insert

the retromuscular mesh and include closer the defect. We show our

multicenter early experience in low resources hospitals in Brazil.

Methods: A review of multicenter a prospectively maintained data-

base of ventral hernia defects evaluation of 39 patients who

underwent laparoscopic e-TEP for ventral, lombar, umbilical and

incisional hernia repair between January 2017 and July 2018. All

patients underwent include in analysis. 60 days post operative out-

comes was evaluation.

Results: All patients underwent include. Almost the same proportion

with 22 male and 17 female. The mean age was 50.7, the body mass

index was 29, the mean operation room time of 147 min. Localization

of defect was preference in medial line with 80% and 20% out.Mean

of size of defect was 5 cm and only 12.8% have more than one defect,

associated diastases 1.9 cm. There is no significant statistic difference

between male and female diastase sizes with p = 0.38. There were no

intraoperative complications. Hematomas was the most complication

with 4 patients, the second was seroma and 1 case of posterior

recurrence. All the complications was treatment with drainage and

good results on minimum follow up 60 days. There is no significant

difference between centers when compare operation room time and

complications.

Conclusion: The early experience in low resources hospitals in Brazil

shows the patients no different outcomes in different centers and

outcomes using e-TEP approach. This technique is reproducible and

can be offer in low resources centers but need surgeon training and

experience to do safely for treatment of ventral and incisional hernias.

P-1271

Robotic surgery experience for the general surgery

resident

Bollenbach S, Ballecer C, Thomas E, Prebil BMaricopa Integrated Health System

Background: Open surgery has been the mainstay for hernia repairs,

however technological advances have led to an ever increasing

number of robotic-assisted surgeries. Thus, the importance of robotic

training for the General Surgery resident cannot be overemphasized.

It is imperative that residents receive training that exposes them to

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S99 Hernia (2019) 23 (Suppl 1):S50–S100

robotic surgery, provides console time, a formal curriculum, and

overcomes other common limitations to training.

Discussion: Despite incorporation of robotic surgery into the general

surgeon’s armamentarium, successful implementation of robotics into

surgery residency curricula has lagged behind. Current literature

highlights resident experience assisting with docking and trocar

placement rather than time on the console. It also suggests that robotic

training interferes with education as a result of limiting exposure to

other laparoscopic or open cases. The University of Alabama estab-

lished a formal curriculum, from which our program adapted their

own resident education protocol. Prior to console time, residents must

complete online robotic training and attend a workshop where they

are introduced to the robot, docking, instrument exchange, simulator

and console training. Residents must complete 6 designated simulator

modules and score 90% or greater, 5 cases as bedside assistant and 5

cases as console surgeon. Our residents accumulate roughly 140

robotic cases during the rotation, 50–75 of which are hernia repairs.

Summary: Based on current literature, there appears to be minimal

console time and limited access to the simulator, hindering training.

Our facility’s experience demonstrates it is possible for residents to

have significant hands-on experience and education, resulting in

proficiency with robotic hernia repairs. Further refinement and

increased implementation of robotic surgery protocols will optimize

robotic training. A major key to success is involvement of attendings

who have demonstrated proficiency and are past their respective

learning curves. A rare scenario in many academic programs.

P-1272

Out come of lichtenstein hernioplasty in rural India

Gandhi CBharati Medical College and Hospital, Sangli, Maharashtra

Inguinal hernia is the commonest surgical disease. Altered ratio of

collagen 1&3 causes weakness of fascia transversalis. Which is the

cause of inguinal hernia. This is a retrospective observational study of

150 inguinal hernioplasty at our institute from 2012 to 2014.

Surgeries were done by faculties and residents. Patients were

followed for 2 years for recurrence and chronic groin pain. We had

0.66% recurrence and 2% mild chronic groin pain at 2 years follow-

up. Not a single case of neurogenic severe or moderate groin pain.

Lichtenstein hernioplasty gives satisfactory long term result for

rural Indian population.

P-1273

Abdominal wall bulging following laparoscopic ventral

hernia repairs


Background: Laparoscopic ventral hernia repairs (LVHR) is one of

most popular operations in general surgery. Postoperative abdominal

wall bulging which was rarely mentioned in the past decades is one of

the common postoperative complications of LVHR. This study aims

at systematic reviewing abdominal wall bulging following LVHR.

Methods: A computer-aided search of the PubMed and Embase

databases was conducted to find relevant English-language publica-

tions on the postoperative abdominal wall bulging of laparoscopic

ventral hernia repairs. The following search terms were used: (la-

paroscopic surgery AND (ventral hernia OR incisional hernia) AND

postoperative complication AND (bulging OR protrusion OR even-

tration OR pseudoreccurence)). No beginning date limit was used.

The search was updated until 31 July 2018. Review articles, meta-

analyses, abstracts, editorials or letters, case reports, tutorials and

guidelines for management articles were excluded. Full-text articles

were then reviewed to definitively determine if the study was eligible

for inclusion.

Results: A total of 11 studies were included for evaluation. The

incidence of LVHR postoperative abdominal wall bulging was

1.3–21.5%. Postoperative abdominal wall bulging may be related to

the area of abdominal wall defect, defect closure in operation, and the

type of implant patch. A patient could be diagnosed as post-LVHR

abdominal wall bulging if he/she meets the criteria in medical history,

clinical features and imaging examination. As preventions, surgeons

should pay attention to recognition and full exposure of fascia defect

edge, returning hernia content, fascia defect closure and patch overlap

and fixation in primary LVHR. When a re-operation is employed,

surgeon could fix a larger mesh tightly over the previous mesh.

Conclusions: Abdominal wall bulging after laparoscopic ventral

hernia repair is not a rare complication and should be diagnosed

carefully. A second surgery is needed when patients dissatisfied with

abdominal wall appearance or dysfunction. Prevention is always

better than treatment.

P-1274

Prospects of hernia and abdominal wall surgery

in China


Nowadays, hernia and abdominal wall surgery is developing rapidly

in China. Not only inguinal hernia, incisional hernia and other

abdominal hernias in open prosthetic repairs are popular in China, but

also laparoscopic and robotic hernia repairs have been carried out

throughout the country. Due to the unbalanced development in dif-

ferent areas of our country, there is still existence of irregular

diagnosis and treatment in hernia. Therefore, Chinese Hernia Society

had published guidelines on diagnosis and treatment of inguinal

hernia in adults (2018 version) and guidelines on diagnosis and

treatment of incisional hernia (2018 version). In addition to this,

Chinese registry of hernia and abdominal wall surgery and quality

control standards are on the threshold of development, although there

is still a long way to go. A few etiology, genetics and molecular

epidemiology studies have been reported, although basic research of

hernia is weak in the whole world. The exact pathogenesis and

inheritance pattern are worth us to further study. The progress of

hernia and abdominal surgery is inseparable from the development of

repair materials. At present, the repair materials are mainly composed

of synthetic materials and biomaterials. The prosthetics related

adverse events in the long term should not be ignored, although

prosthetic repairs can reduce postoperative hernia recurrence rate.

Mesh shrinkage, erosion, adhesion and infection are all common

complications, as the spread of standard treatment, these postopera-

tive complications may phase down. Researchers had made some

innovations on materials science, textile science and even bioengi-

neering, although there is no ideal repair material yet, the future of

materials is worthy of the expectation of hernia and abdominal wall

surgeons.

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Videos


V-1041

Mesh non-fixation in laparoscopic transabdominal

preperitoneal (TAPP) inguinal hernia repair: technique

padronization

Neves V, Madureira F, Iglesias A, Rodrigues HHospital Universitario Gaffree e Guinle

Introduction: The laparoscopic repair of inguinal hernia by the TAPP

technique requires a stapler to fix the mesh, making the method

expensive. This article proposes the use of a modified technique for

the repair of inguinal hernia, trying to offer a cheaper method and

with less chronic pain.

Methods: 19 patients were operated at the Hospital Universitario

Gaffree e Guinle. All submitted to videolaparoscopic TAPP inguinal

hernioplasty with polypropylene mesh and non-fixation.

Discussion: There was no recurrence in the operated hernias, which

suggests a safe procedure. There was also no incidence of pain after

the 30th PO. The incidence of surgical site infection was 5.3%, which

was within the expected range.

Conclusion: The chosen technique seems safe as well as lower cost

than the traditional one.

V-1083

A case of bilateral spigelian hernia repair

Fazendin J, Fazendin A, Fazendin E, Onopchencko AHahnemann University Hospital

Spigelian hernias comprise a small minority (1–2%) of all abdominal

wall defects. Even more rare is the incidence of bilateral Spigelian

hernias in the adult population. Laparoscopic repair of abdominal wall

hernias has been proven safe and effective. However, due to the rarity

of these hernias, there are no large case series to provide a consensus

for best approach. Trans-abdominal, totally extra-peritoneal and trans-

abdominal pre-peritoneal approaches have all been proven to be

effective. In this video we present an interesting case of bilateral

Spigelian hernias treated by laparoscopic trans-abdominal pre-peri-

toneal repair. We make special emphasis on the importance of trocar

placement for optimal management of this rare condition.

V-1126

Reverse-Tar: maximizing mesh overlap on open flank

hernia repair

Tastaldi L, Alkhatib H, Fafaj A, Petro C, Svestka M,

Rosenblatt S, Krpata D, Rosen M, Prabhu ACleveland Clinic

We aim to present an educational video demonstrating a novel

approach to allow for the extension of mesh overlap into the midline

during open flank hernia repair. For such, we selected the case of a

50-year old female who presented to the Hernia Clinic with a large

traumatic flank hernia resultant of an MVA. The patient had no prior

abdominal operations, had a BMI of 31 and was a lifetime non-

smoker. Preoperative CT-SCAN demonstrated an 11 cm flank hernia

with herniation of colon and small bowel, resultant from evident

avulsion of the musculature of the lateral abdominal wall.

In such an approach, the patient is positioned in lateral decubitus,

and a traditional open flank incision is performed. Upon dividing the

muscles of the lateral abdominal wall, the preperitoneal space is

developed in all directions; the border of the psoas muscle is identi-

fied medially. The innovation of this technique consists in incising the

peritoneum invested in the posterior rectus sheath, dividing the

transversus abdominis fibers and finally incising the posterior lamella

of the internal oblique, gaining access to the retromuscular space. As

such, the retromuscular space is dissected in the direction of linea

alba, and a wide pocket for extending mesh overlap into the midline is

created. This surgical maneuver is particularly helpful to ensure

adequate mesh overage in all directions when repairing large flank

hernias. Note that in this approach, we perform the same dissection of

a TAR, but in a reverse manner: from preperitoneal to retromuscular

space. The repair was completed with two large pieces of permanent

synthetic mesh that were sewed together, placed as a sublay and

fixated with transfascial sutures. The video we intend to present

demonstrates the technique step-by-step, and we argue that has a

strong educational purpose for the audience.

V-1155

Laparoscopic approach for patients with refractory

postoperative chronic pain

Narita M, Hata H, Matsusue R, Yamaguchi T, Otani T, Ikai

IKyoto Medical Center

Background and aim: Postoperative chronic pain (POCP) is com-

plex disease and there is no standard of care for refractory cases. We

have operated POCP patients who were refractory for conservative

therapy. The aim of this study was to present our laparoscopic sur-

gical technique for patients with refractory postoperative chronic

pain.

VIDEO ABSTRACTS

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Hernia (2019) 23 (Suppl 1):S101–S103

Patients and methods: We evaluated 5 patients who underwent

surgical intervention via laparoscopic approach between 2013 and

2018 in the treatment of POCP, which was refractory for conservative

therapy.

Results: Four patients were male and the median age was 61 years

(ranging from 50 to 69). Median duration between primary surgery

and surgical intervention in the treatment of POCP was 23.4 months

(ranging from 12.9 to 43.0 months). Case 1 who had neuralgia of

iliohypogastric nerve underwent laparoscopic tripleneurectomy via

retroperitoneal approach. Case 2 who had nociceptive pain and dys-

uria following inguinal hernia repair using transinguinal preperitoneal

approach underwent mesh removal via laparoscopy. Three patients

(case 3–5) who had meralgia paresthetica underwent partial mesh

removal using laparoscopic approach. In case 2, surgical intervention

resulted in cure of dysuria but mild pain remained. Pain completely

disappeared immediately after surgery in the remaining 4 patients.

Conclusions: Laparoscopic approach is effective treatment option for

selected patients with refractory POCP.

V-1177

Robotic repair of an iatrogenic diaphragmatic hernia

Petro C, Petro C, Alkhatib H, Fafaj A, Tastaldi L, Prabhu ACleveland Clinic

Introduction: A 55-year-old man presented with a painful left

diaphragmatic hernia 8 years after a liver transplant, likely due to a

retraction injury.

Methods: The patient was placed in the supine position and after

laparoscopic access, adhesiolysis and port placement, the robotic

platform was used to dissect and reduce the incarcerated hernia

contents. The defect was closed with interrupted figure-of-eights

using braided 0 nylon suture. Mesh reinforcement was not utilized.

Results: The patient was discharged on postoperative day 2 after

resolution of transient nausea. He followed-up at 1 month with res-

olution of his preoperative pain and he was otherwise well.

Conclusion: The robotic approach can facilitate the repair of

diaphragmatic hernias high in the chest that may otherwise be chal-

lenging to access by open or traditional laparoscopic platforms.

V-1179

The challenging inguinal hernioplasty

Doerhoff CCapitol Region Medical Center

Background: 1 in 7 males will require inguinal hernia repair. Robotic

radical prostatectomy’s (RRP) are performed on 95% of patients who

meet criteria for removal of prostate cancer. The challenging inguinal

hernioplasty is a patient with both RRP and preperitoneal mesh.

Discussion: In the author’s opinion Find fat and begin lateral to

medial dissection. Midline dissection to pubic symphysis. Find

coopers ligaments. Locate any cord structure. Extended retroperi-

toneal dissection. 15 cm x 20 cm mesh. Use TSM mesh if insufficient

peritoneum to cover mesh. Reduce IAP to 8 mmHg. Utilize reliable

fixation (e.g. tacks to Coopers, fibrin glue to soft tissue, and double

crown non-absorbable suture to cephalad portion of mesh.)

Methods: Patient 1: Status post RRP with plug repair has recurrent

LIH and nonrecurrent RIH. Patient 2: Failed LIH TAPP and failed

open plug patch repair of recurrence. Patient 3: Failed TAPP for large

right scrotal hernia.

Conclusion: The robot has facilitated inguinal hernioplasty. How-

ever, there remain challenging repairs for patients who have RRP and/

or previous hernia repair with preperitoneal mesh. Methodical dis-

section and patience is necessary for safe hernioplasty of challenging

defects.

V-1194

Robotic repair of spigelian hernia

Arefanian S, Frisella M, Miller M, Blatnik JWashington University in Saint Louis

Background: Spigelian hernia is a rare type of hernia that occurs in

the lateral border of rectus abdominis muscle. Different methods have

been used for surgical repair of this abdominal wall defect, including

open and laparoscopic techniques. Here we present the robotic-as-

sisted repair of a left side Spigelian hernia.

Description: A 56-year-old male presented with the left flank bulge

that was increasing in size as well as constipation and discomfort. He

had a large left Spigelian hernia with an approximate size of

5 9 5 cm. He underwent a robotic-assisted hernia repair with syn-

thetic mesh. The patient tolerated the surgery and postoperative

course well.

Conclusion: Robotic-assisted Spigelia hernia repair is a new tech-

nique for repair of this uncommon hernia with acceptable and

satisfying results.

V-1196

Robotic explantation after robotic transabdominal

preperitoneal inguinal hernia repair for chronic pain

Tchokouani L, Jacob BThe Mount Sinai Medical Center

This is a 49-year-old man experiencing a pulling and nocioceptive

chronic pain since undergoing a robotic bilateral inguinal hernia

repair 1 year prior to evaluation. After undergoing all the proper

workup including, but was not limited to, imaging, injections and

physical therapy, he decided to pursue surgical mesh excision. First, a

diagnostic laparoscopy was performed with subsequent standard port

placement for a Robotic Transabdominal Preperitoneal hernia repair.

The mesh was identified and meticulously dissected away from the

major inguinal structures. We were able to identify and preserve most

of the genitofemoral nerves, the gonadal vessels, the vas deferens, the

inferior epigastric vessels, the iliac arteries and veins bilaterally. A

small piece of mesh was left along the posterior surface of the right

inferior epigastric vessels where it met the iliac vessels. The left side

was dissected in similar fashion. There was no more mesh connecting

the right and left groins as identified during the preoperative evalu-

ation. All the other mesh was explanted completely in combined total

of 5 large pieces. We were able to preserve a preperitoneal flap in the

central portion of the explantation zone, but we had to sacrifice

peritoneum at the lateral edges of the dissection where it was thin.

Once the explant was complete we proceeded to close the peritoneum.

The patient reported improved symptoms after mesh removal at the

follow up appointments and is much happier. In conclusion, patients

who present with chronic pain after inguinal hernia repair should be

carefully assessed and worked up to treat the true etiology of their

symptoms. The dogma of acceptable chronic pain after inguinal

hernia repair should be challenged and every patient given individ-

ualized treatment.

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V-1242

Robotic approach for recurrent inguinal hernias

after repairs with previous preperitoneal mesh

Amaral P, Pivetta L, Barros P, Hernani B, Neto I, Franciss

M, Tastaldi L, Altenfelder Silva R, Roll SHospital Alemao Oswaldo Cruz

Supporters of the robotic platform argue that enhanced visualization,

improved surgeon ergonomics and refined precision of movements

are all factors that make such robotic-assisted laparoscopy superior to

the standard laparoscopic approach. Reoperative fields with previous

preperitoneal mesh such as those in recurrent inguinal hernias after

prior laparoscopic repairs are challenging clinical scenarios in which

these potential benefits of the robotic platform are desirable. Histor-

ically, our group treated recurrent inguinal hernias after laparoscopic

repairs using open approaches. With the availability of the robotic

platform at our institution and after gradually overcoming the learning

curve, we have transitioned to treat such recurrences through a robotic

transabdominal preperitoneal approach (r-TAPP). In this video, we

present the case of a 72-year male with a multiply recurrent bilateral

inguinal hernias after two failed laparoscopic approaches (TEP and

TAPP). PSH includes a remote history of a laparoscopic gastric

bypass, placement of a penile prosthesis and CABG. A CT scan

demonstrated bilateral recurrent inguinal hernias with the penile

prosthesis device being in the middle of the operative field.

In this video, we present step-by-step, an r-TAPP approach to deal

with these challenging cases. In summary, a large peritoneal flap was

created, and bilateral direct recurrences were noted (M3). The penile

prosthesis was dissected out of the operative field, and the hernia sacs

were reduced of the direct defects were reduced. In this case, the prior

meshes were partially removed, and new permanent synthetic meshes

were placed and fixated. Patient recovery was uneventful and is now

6 months after the operation without a hernia recurrence.

V-1249

Laparoscopic approach for Etep transversus abdominis

release (TAR)


Jarufe N, Pimentel FPontificia Universidad Catolica de Chile

Posterior component separation with TAR during abdominal wall

reconstruction for ventral hernias has become popular in many hos-

pitals around the world. Minimally invasive approach can help to

reduce wound complications but its associated to a long learning

curve,

As a developing country we do not have a robot available so we

began our experience in laparoscopic TAR 1 year ago and we have

performed over 10 procedures now with very good perioperative

results.

We present a fulHD video (1080p) of the main steps of a lap TAR

with an eTEP approach and the key tips and tricks to achieve the

procedure at the beginning of the learning curve.

V-1269

No hernia too far: a robotic approach to a flank hernia

Weimer S, Ballecer CMaricopa Medical Center, Center for Minimally Invasive Robotic

Surgery

A 53 year old male is referred for a large left flank hernia that

developed after a thoracoabdominal incision for exposure during an

L4 laminectomy. He has had persistent discomfort with activity and a

large, unsightly bulge on his left flank at the site of the incision. A CT

scan confirmed a left flank hernia 10 cm 9 15 cm containing colon

and small bowel. We performed an rTAPP left flank incisional hernia

repair with mesh with the patient in a right lateral decubitus position.

The patient did well and was discharged post-operative day 1.

V-1275

Laparoscopic approach to recurrent hernia

after cystectomy and laparoscopic paraileal conduit

hernia repair

Lo Menzo E, Fonseca Mora M, Milla Matute C, Rivera C,

Ortiz Gomez C, Shah R, Szomstein S, Rosenthal RCleveland Clinic Florida

Introduction: Patients with Urothelial Cancer who undergo

Laparoscopic Cystectomy may develop Incisional hernia or paras-

tomal hernia in approximately 22.8% and 18% of the cases

respectively. The aim of this video is to illustrate the management of a

patient who developed recurrent suprapubic hernia after laparoscopic

paraileostomy hernia repair.

Method: A 76 year-old male, with a 1-year history of para-ileal

conduit hernia, is seen in clinic for recurrent suprapubic hernia after a

previous laparoscopic para ileal conduit hernia. The CT-shows small

defect in the inguinal space and weakness of the rectus muscle above

the symphysis. Following insertion of trocars, dissection of the

omentum was performed. Previous mesh was in adequate position

with no recurrence. No para-ileoal recurrence was observed, however

a left direct suprapubic hernia with significant laxity of the left lower

quadrant were evident. Following identification of Cooper�s ligament,

a 25 9 20 cm Ventralight mesh was placed using 1# PDS sutures.

Through stab wound incision the sutures were pulled out through the

abdominal wall, the mesh is fixed and taut adequately. Using per-

manent tacks, the mesh was secured circumferentially. The patient

tolerated well the procedure and was discharged on the same day.

Conclusion: Redo laparoscopic hernia after previous laparoscopic

para ileal conduit hernia is feasible and safe.

123

Hernia (2019) 23 (Suppl 1):S101–S103 S103

Author Index


Author IndexAbdelfatah E, IP-1294, S35

Abidi H, P-1136, S75

Achurra P, P-1178, S82, P-1243, S94, V-1249, S103

Adams E, P-1195, S85

Addo A, FP-1222, S24, FP-1226, S13, P-1228, S92

Adelman D, P-1143, S77, P-1144, S77

Adrales G, IP-1305, S8, IP-1315, S13, IP-1323, S21, P-1204, S86

Agca B, P-1005, S50, P-1026, S56, P-1034, S57, P-1090, S68

Agrawal D, P-1188, S84

Aguado Suarez N, P-1010, S52, P-1011, S52, P-1012, S52,

P-1014, S53

Ahmed F, P-1131, S74

Ahonen J, FP-1093, S11

Akhmetov A, P-1086, S67, P-1087, S67

Alaqel M, P-1109, S71, P-1110, S71, P-1111, S72

Alayon-Rosario M, P-1258, S97

AlBalawi M, P-1109, S71, P-1110, S71, P-1111, S72

Albayrak N, P-1030, S56

Albertson S, P-1217, S90

Albin D, P-1046, S59

Albin M, P-1046, S59

Aldohayan A, P-1106, S70, P-1109, S71, P-1110, S71, P-1111, S72

Aleman R, P-1180, S82

Alimi Y, P-1214, S89

Alkhatib H, FP-1122, S41, FP-1123, S17, P-1021, S55, P-1190, S84,

P-1245, S95, P-1263, S98, V-1126, S101, V-1177, S102,

V-1186, S27

Allamaneni S, P-1017, S54, P-1018, S54

Allen D, FP-1233, S44

Allen G, P-1076, S64

Allen J, FP-1247, S44

Altenfelder Silva R, FP-1137, S46, FP-1244, S10, P-1139, S76,

P-1142, S76, P-1207, S87, V-1242, S103

Altimari M, FP-1064, S109

Alvarez R, IP-1309, S12

Amaral P, P-1146, S77, P-1207, S87, V-1242, S103

Amler E, FP-1202, S18

Anders S, P-1004, S50

Anthony A, P-1035, S58

Appleby P, FP-1235, S42, P-1248, S95, P-1253, S95, P-1259, S97,

P-1264, S98

Araujo T, P-1239, S94

Arbouz M, P-1049, S60

Arefanian S, FP-1168, S30, V-1194, S102

Arguello-Angarita M, P-1100, S69

Arias Pacheco R, P-1008, S51, P-1009, S51, P-1010, S52,

P-1011, S52, P-1012, S52, P-1013, S53, P-1014, S53

Arnold M, P-1206, S87

Assef J, P-1139, S76

Augenstein V, FP-1037, S47, FP-1075, S23, FP-1097, S47,

FP-1124, S17, FP-1125, S26, FP-1127, S29, P-1128, S73,

P-1129, S73, P-1206, S87, P-1229, S93, V-1119, S27

Awad S, P-1065, S62

Azevedo M, P-1270, S99

Bachman S, IP-1301, S8, IP-1330, S25

Baker S, P-1102, S70

Bakker W, FP-1089, S40, P-1088, S67, P-1091, S68

Balla F, P-1101, S69

Ballecer C, IP-1284, S33, IP-1331, S25, P-1271, S99, V-1269, S103

Banks-Venegoni A, FP-1044, S46

Bansal D, FP-1053, S45

Barchi L, P-1207, S87

Barkan A, FP-1233, S44

Barrio M, P-1199, S86

Barrios C, P-1217, S90

Barros P, FP-1244, S10, P-1139, S76, P-1146, S77, P-1207, S87,

V-1242, S103

Barros R, P-1139, S76

Bass B, IP-1322, S21

Bassas R, P-1109, S71, P-1110, S71, P-1111, S72

Bastos C, P-1213, S89

Bastos R, P-1140, S76

Bates A, FP-1145, S26

Batistela F, P-1211, S89

Beck W, P-1063, S62

Becker N, P-1065, S62

Beffa L, P-1016, S53

Bellini A, P-1208, S88

Belyansky I, IP-1308, S9, FP-1222, S24, FP-1226, S13, P-1228, S92

Benvenuto M, IP-1320, S19

Berger D, FP-1260, S16, P-1084, S66

Bernardi K, FP-1260, S16, FP-1261, S39, P-1254, S96, P-1255, S96,

P-1257, S97

Bhanot P, P-1214, S89

Bhavaraju A, P-1063, S62

Bicket M, P-1204, S86

Bilezikian J, FP-1235, S42, P-1248, S95, P-1253, S95, P-1259, S97,

P-1262, S98, P-1264, S98

Billow D, FP-1176, S47

Birolini C, P-1067, S63, P-1197, S86, P-1211, S89

Bisgaard T, IP-1296, S19

Blatnik J, FP-1123, S17, FP-1168, S30, V-1194, S102

Blonk L, IP-1286, S25

Bock S, P-1266, S99

Bolduc A, IP-1344, S32

Bollenbach S, P-1271, S99

Bonjer J, IP-1286, S25

Brandalise A, IP-1297, S36

Brandi C, IP-1283, S49

Brandt J, P-1029, S56

Brasil H, P-1207, S87

Brathwaite C, FP-1233, S44

Broach R, FP-1173, S43

Broda A, FP-1222, S24, FP-1226, S13, P-1228, S92

Brown S, P-1227, S92

Bruni P, IP-1278, S31

ABSTRACTS

123

Hernia (2019) 23 (Suppl 1):S104–S109

Bryczkowski S, IP-1293, S34, IP-1294, S35,

IP-1295, S34

Buckley T, P-1238, S93

Budney S, FP-1191, S14

Burgmans I, FP-1089, S40, P-1088, S67

Burgmans J, P-1091, S68, P-1092, S68

Cabrera P, P-1165, S80, P-1169, S81

Cai M, FP-1057, S40

Camila O, P-1218, S90, P-1220, S91

Campanelli G, IP-1278, S31

Campos Alvarez C, P-1006, S50, P-1007, S51, P-1008, S51,

P-1009, S51, P-1013, S53

Canccado A, P-1223, S91, P-1225, S92

Caparelli M, P-1017, S54, P-1018, S54, P-1023, S56

Carbonell A, FP-1224, S29, FP-1247, S44, P-1258, S97

Carlos R, P-1220, S91

Carrasco J, P-1162, S80, P-1268, S99

Casas F, P-1165, S80

Caso R, P-1214, S89

Castagneto G, IP-1292, S49

Castillo A, P-1169, S81

Castillo C, P-1162, S80, P-1268, S99

Cavalli M, IP-1278, S31

Cavazzola L, P-1113, S72, P-1115, S72, P-1239, S94, P-1270, S99

Ceno M, P-1084, S66

Ceppa E, P-1199, S86

Cerqueira C, P-1223, S91

Cervone A, P-1029, S56

Chai C, P-1065, S62

Chan D, P-1056, S61, P-1069, S63, P-1103, S70

Chen D, IP-1328, S25, FP-1137, S46, P-1142, S76

Chen J, FP-1163, S18, P-1073, S64, P-1159, S79, P-1161, S80,

P-1172, S81

Chen Y, P-1204, S86

Cherasard P, FP-1233, S44

Cherla D, FP-1260, S16

Chiu L, P-1065, S62

Christensen A, P-1266, S99

Claus C, IP-1360, S49, P-1115, S72, P-1270, S99

Clevers G, P-1088, S67, P-1092, S68

Cobb W, FP-1224, S29, FP-1247, S44, P-1258, S97

Colavita P, FP-1075, S23, FP-1124, S17, FP-1125, S26,

FP-1127, S29, P-1129, S73, P-1206, S87, P-1229, S93

Collister P, P-1227, S92

Conway R, FP-1044, S46

Cook M, FP-1141, S18

Copin Tenorio R, P-1142, S76

Cornwell K, P-1143, S77, P-1144, S77

Crain N, P-1071, S63, P-1072, S63

Crespo A, P-1140, S76

Cristian M, P-1218, S90, P-1220, S91

Crovari F, P-1178, S82, P-1243, S94, V-1249, S103

Cunha C, P-1113, S72, P-1140, S76

Cunha L, P-1213, S89, P-1223, S91, P-1225, S92

Cunha V, P-1213, S89

Damous L, P-1067, S63

Damous S, P-1067, S63, P-1197, S86, P-1211, S89

Davenport D, P-1238, S93

Davids P, P-1088, S67, P-1092, S68

Davis B, P-1063, S62

Davis S, P-1101, S69

de Beaux A, FP-1202, S18

de la Torre J, P-1167, S81

de Paz Mora�n M, P-1014, S53

de Virgilio C, FP-1265, S23

Dean K, FP-1247, S44

Dearth C, FP-1246, S40

Delgado Sevillano R, P-1006, S50, P-1007, S51, P-1008, S51,

P-1009, S51, P-1012, S52

DeLong C, P-1193, S85

Demare A, FP-1171, S13, FP-1230, S42

Denney B, P-1167, S81

DeVitis J, IP-1347, S34, FP-1044, S46

Devulapali C, P-1214, S89

Dhadlie S, P-1055, S60

Dhakad D, P-1032, S57

Dimick J, FP-1276, S41

Divin R, FP-1202, S18

Doble J, FP-1189, S16

Docimo S, IP-1342, S32, FP-1145, S26, IP-1349, S37

Doerhoff C, P-1184, S83, V-1179, S102

Dominguez C, P-1162, S80, P-1268, S99

Dooley D, FP-1141, S18, P-1195, S85

Dorado E, IP-1298, S21

Dourado M, P-1225, S92

Drevets P, P-1076, S64

Dubina E, FP-1265, S23

Dumanian G, IP-1316, S15, FP-1061, S22

Duncan M, P-1204, S86

Dutra V, P-1223, S91

East B, FP-1202, S18, P-1149, S78, P-1187, S84

Eckhauser F, P-1253, S95

Eid M, P-1209, S88

Escobar R, P-1048, S59

Estep A, FP-1222, S24, P-1228, S92

Evans K, P-1214, S89

Eveland A, P-1200, S86

Everitt J, P-1047, S59

Ewing A, FP-1224, S29

Fadaee N, P-1148, S78

Fafaj A, IP-1332, S26, FP-1122, S41, FP-1123, S17,

FP-1176, S47, P-1190, S84, P-1245, S95, P-1263, S98,

V-1126, S101, V-1177, S102, V-1186, S27

Falola R, P-1214, S89

Fan H, P-1069, S63

Fantauzzi M, P-1139, S76

Faro Junior M, P-1197, S86, P-1211, S89

Farrell B, P-1135, S75

Favacho B, FP-1137, S46

Fazendin A, V-1083, S101

Fazendin E, V-1083, S101

Fazendin J, V-1083, S101

Felix E, IP-1329, S25

Feng K, P-1102, S70

Fernando Rodrigues Alves de Moura L, P-1077, S65, P-1078, S65,

P-1081, S66, P-1082, S66

Ferreira F, P-1146, S77

Ferzoco S, P-1135, S75

Feustel P, P-1192, S85

Feyerherd P, FP-1153, S45

Figueroa C, P-1217, S90

Filipi C, IP-1348, S36, P-1142, S76

Fillion M, P-1262, S68

Fischer J, IP-1340, S32, FP-1173, S43

Fisher O, P-1103, S70

Fitzgibbons D, P-1188, S84

Fitzgibbons R, P-1074, S64, P-1227, S92

Fogacca de Barros P, FP-1137, S46, P-1142, S76

Fonseca C, P-1180, S82

Fonseca Mora M, P-1205, S87, P-1208, S88, V-1275, S103

Forman B, FP-1216, S17, FP-1231, S23, P-1251, S95

Fortelny R, IP-1354, S38

Foster A, FP-1247, S44

Foster L, P-1107, S70

Fox S, FP-1247, S44

Fracol M, FP-1061, S22

Franciss M, V-1242, S103

Frederix G, P-1092, S68

123

S105 Hernia (2019) 23 (Suppl 1):S104–S109

Freitas do Amaral P, FP-1137, S46

Frey A, P-1215, S90

Frieder J, P-1180, S82, P-1205, S87, P-1208, S88, P-1210, S88

Frisella M, V-1194, S102

Frunder A, IP-1290, S36

Funk L, FP-1064, S109, P-1080, S65

Furtado M, P-1115, S72

Furukawa T, V-1132, S27

Gagliano R, FP-1191, S14, P-1234, S93

Gandhi C, P-1272, S100

Ganga R, P-1210, S88

Garcia Bear I, P-1006, S50, P-1007, S51, P-1008, S51, P-1009, S51,

P-1010, S52, P-1011, S52, P-1012, S52, P-1013, S53, P-1014, S53

Garcia D, P-1146, S77

Gbozah K, FP-1127, S29, V-1119, S27

Ghanem O, FP-1198, S22

Gibson H, IP-1284, S33

Gillespie T, FP-1191, S14, P-1234, S93, P-1240, S94

Gillian G, FP-1053, S45

Gillory L, P-1065, S62

Giron F, P-1048, S59

Glanville J, P-1100, S69

Gleason F, P-1102, S70

Goldblatt M, IP-1339, S31, P-1039, S58

Gong D, P-1117, S73

Gonzalez A, P-1165, S80, P-1169, S81

Green J, P-1047, S59

Greenberg J, FP-1064, S109, P-1080, S65

Greenberg Y, P-1079, S65

Greenhalgh E, P-1135, S75

Greiffenstein P, FP-1141, S18, FP-1267, S29

Griscom T, P-1258, S97

Grossi J, P-1270, S99

Guimaraes V, P-1213, S89, P-1223, S91, P-1225, S92

Gupta A, P-1100, S69

Gus J, P-1113, S72

Gutierrez Corral N, P-1006, S50, P-1007, S51, P-1010, S52,

P-1011, S52, P-1012, S52

Gutjahr D, P-1019, S54, P-1020, S55

Gvenetadze T, FP-1118, S10

Halka J, FP-1171, S13, FP-1230, S42

Hall K, FP-1233, S44

Harder F, P-1019, S54, P-1020, S55

Haridi A, P-1049, S60

Harmon J, P-1204, S86

Harner A, P-1076, S64

Harold K, IP-1359, S49

Harris H, IP-1353, S38

Hashim D, P-1030, S56

Hata H, V-1155, S101

Haubert L, P-1151, S79

Haynes S, P-1138, S75

Helm M, P-1039, S58

Hendriksen B, FP-1189, S16

Heniford B, IP-1321, S20, IP-1334, S28, FP-1075, S23,

FP-1097, S47, FP-1124, S17, FP-1125, S26, FP-1127, S29,

P-1128, S73, P-1129, S73, P-1206, S87, P-1229, S93, V-1119, S27

Hensman C, P-1035, S58

Hernandez J, P-1048, S59

Hernandez-Granados P, IP-1285, S32

Hernani B, FP-1137, S46, P-1139, S76, P-1146, S77, V-1242, S103

Hewett P, P-1035, S58

Higgins R, IP-1341, S32

Hilfinger U, FP-1153, S45

Hilton L, P-1076, S64

Hlavacek C, P-1215, S90

Hobler S, P-1017, S54, P-1018, S54, P-1023, S56

Hodgdon I, FP-1141, S18, FP-1267, S29, P-1195, S85

Holihan J, FP-1260, S16, P-1254, S96

Hollenbeak C, FP-1189, S16

Holsten S, P-1076, S64

Hope W, FP-1235, S42, FP-1261, S39, P-1248, S95, P-1253, S95, P-1259,

S97, P-1262, S98, P-1264, S98

Hoskovec D, FP-1153, S45

House M, P-1199, S86

Howell R, FP-1233, S44

Huadong D, P-1152, S79

Huang D, P-1240, S94

Huang L, P-1080, S65

Hughes T, FP-1261, S39, P-1238, S93

Huntington C, FP-1075, S23, P-1206, S87

Iacco A, FP-1171, S13, FP-1230, S42

Ibrahim M, P-1047, S59

Ierardi K, P-1016, S53

Iglesias A, V-1041, S101

Ikai I, V-1155, S101

Imazu H, P-1108, S71

Imazu Y, P-1108, S71

Iscan A, P-1005, S50

Iscan Y, P-1026, S56, P-1034, S57, P-1090, S68

Israel I, FP-1235, S42, P-1248, S95, P-1253, S95, P-1259, S97,

P-1262, S92, P-1264, S98

Israr S, FP-1191, S14

Ivarsson M, FP-1093, S11

Jackson B, P-1214, S89

Jackson J, P-1039, S58

Jacob B, IP-1299, S8, V-1196, S102

Jacubovsky I, P-1178, S82, P-1243, S94, V-1249, S103

Jafri S, FP-1276, S41

Jain M, P-1022, S55

Janczyk R, FP-1171, S13, FP-1230, S42

Janes L, FP-1061, S22

Janis J, IP-1324, S21, IP-1338, S28

Jarufe N, P-1178, S82, P-1243, S94, V-1249, S103

Jauregui C, P-1162, S80, P-1268, S99

Jeekel J, IP-1351, S38

Joel F, P-1218, S90

Johnson E, IP-1282, S36

Jorge Barreiro J, P-1006, S50, P-1007, S51, P-1008, S51,

P-1009, S51, P-1010, S52, P-1011, S52, P-1012, S52,

P-1013, S53, P-1014, S53

Kadamani A, P-1165, S80, P-1169, S81

Kallinowski F, P-1019, S54, P-1020, S55

Kao A, FP-1075, S23, P-1229, S93

Kao L, P-1254, S96, P-1255, S96, P-1257, S97

Karatassas A, P-1035, S58

Karim S, P-1063, S62

Karip B, P-1090, S68

Kashchenko V, P-1086, S67, P-1087, S67

Kasten K, P-1229, S93

Kawamoto Fujikawa V, P-1142, S76

Kercher K, FP-1075, S23

Kerkman T, FP-1089, S40

Khoury J, P-1094, S69

Kim D, FP-1265, S23

Kircher C, P-1136, S75

Kirkpatrick S, P-1094, S69

Kitagawa Y, V-1132, S27

Klobusicky P, FP-1153, S45

Ko T, FP-1260, S16, FP-1261, S39, P-1254, S96, P-1255, S96,

P-1257, S97

Koebe S, P-1080, S65

Kottmann T, P-1084, S66

Kozak G, FP-1173, S43

Kozieł S, P-1182, S83, P-1183, S83

Krikhely A, FP-1198, S22

123

Hernia (2019) 23 (Suppl 1):S104–S109 S106

Krpata D, IP-1313, S12, FP-1122, S41, FP-1123, S17,

FP-1176, S47, FP-1244, S10, P-1021, S55, P-1131, S74,

P-1190, S84, P-1245, S95, P-1263, S98, V-1126, S101, V-1186, S27

Kumaira Fonseca M, P-1113, S72, P-1140, S76

Kurapati S, P-1167, S81

Landry M, FP-1216, S17, FP-1231, S23

Langstein H, P-1135, S75

Larsen N, P-1188, S84

Lau F, FP-1267, S29

Lechner M, IP-1290, S36

Ledet C, IP-1284, S33

Lee B, P-1234, S93

Lee D, P-1065, S62

Lee L, IP-1318, S19

Leiman D, P-1164, S80, P-1174, S82

Leonardi C, P-1195, S85

Leopardi L, P-1035, S58

Levinson H, P-1047, S59

Lew M, FP-1216, S17, FP-1231, S23

Lewis J, P-1029, S56

Lewis R, FP-1216, S17, FP-1231, S23, P-1251, S95

Leyba M, IP-1346, S34

Li B, P-1117, S73

Li S, FP-1057, S40, P-1058, S61, P-1059, S61, P-1273, S100,

P-1274, S100

Li Y, P-1117, S73

Liacouras P, FP-1246

Liang M, FP-1260, S16, FP-1261, S39, P-1254, S96, P-1255, S96,

P-1257, S97

Lidor A, FP-1064, S109, P-1080, S65

Lighter M, P-1256, S96

Lima Konichi R, P-1142, S76

Limmer A, IP-1284, S33

Lin E, P-1101, S69

Lincourt A, P-1229, S93

Lischke R, FP-1202, S18, P-1149, S78

Liu N, FP-1064, S109

Lo Menzo E, P-1180, S82, P-1205, S87, P-1208, S88, P-1210, S88,

P-1218, S90, P-1220, S91, V-1275, S103

Lodygin A, P-1086, S67, P-1087, S67

Loi K, P-1056, S61

Lombardo F, IP-1278, S31

Loor M, P-1151, S79

Lorenz R, IP-1290, S36

Lorenzetti C, IP-1297, S36

Lourie D, IP-1289, S9

Love W, FP-1224, S29, FP-1247, S44

Lu R, FP-1222, S24, FP-1226, S13, P-1228, S92

Luciano T, P-1263, S98

Lundberg J, P-1234, S93

Ly J, P-1107

Lyons N, P-1254, S96, P-1255, S96, P-1257, S97

Maddern G, P-1035, S58

Madris B, P-1134, S74

Madureira F, V-1041, S101

Mak J, P-1107, S70

Makris K, P-1065, S62

Malcher F, FP-1198, S22, P-1115, S72

Malik D, P-1032, S57

Maloley-Lewis B, P-1227, S92

Maloney S, FP-1037, S47, FP-1075, S23, FP-1097, S47,

FP-1124, S17, FP-1125, S26, FP-1127, S29, P-1128, S73,

P-1129, S73, P-1229, S93, V-1119, S27

Manieri C, P-1054, S60

Maria F, P-1218, S90, P-1220, S91

Martinez G, P-1268, S99

Martins de Oliveira Neto R, P-1077, S65, P-1078, S65, P-1081, S66,

P-1082, S66

Matsusue R, V-1155, S101

Mazer L, P-1148, S78

Mazpule G, IP-1293, S34, IP-1294, S35, IP-1295, S34, FP-1237, S46,

P-1100, S69

McCoy K, P-1134, S74, P-1200, S86

Meara M, IP-1307, S9

Medjamea A, P-1049, S60

Mehta A, FP-1198, S22

Mejahdi S, P-1049, S60

Meknat A, P-1079, S65

Meliani B, P-1049, S60

Memisoglu K, P-1034, S57, P-1090, S68

Mendes R, P-1223, S91, P-1225, S92

Mesko N, FP-1176, S47

Messa C, FP-1173, S43

Meyer F, P-1030, S56

Miao J, P-1117, S73

Mickova A, FP-1202, S18

Milla C, P-1180, S82

Milla Matute C, P-1205, S87, P-1208, S88, P-1210, S88,

V-1275, S103

Miller H, P-1266, S99

Miller M, FP-1168, S30, V-1194, S102

Milton A, FP-1261, S39, P-1254, S96, P-1255, S96, P-1257, S97

Minguez Ruiz G, P-1006, S50, P-1007, S51, P-1009, S51,

P-1010, S52, P-1011, S52, P-1012, S52, P-1013, S53, P-1014, S53

Minkowitz H, P-1164, S80, P-1174, S82

Miranda J, P-1067, S63

Mitchell A, P-1076, S64

Mitsinskaya A, P-1086, S67, P-1087, S67

Mitsinskii M, P-1086, S67, P-1087, S67

Mitura K, P-1181, S83, P-1182, S83, P-1183, S83

Mo S, P-1103, S70

Moazzez A, FP-1265, S23

Montero E, P-1067, S63

Montgomery A, IP-1352, S38

Morales-Conde S, IP-1280, S31

Morelli C, P-1178, S82

Morfesis F, P-1031, S57, P-1040, S59

Morlacchi A, IP-1278, S31

Morrell D, FP-1166, S45, FP-1189, S16

Morris M, P-1102, S70

Morrison J, IP-1327, S25

Mosquera M, P-1165, S80, P-1169, S81

Mukkai Krishnamurty D, P-1227, S92

Munoz R, P-1178, S82, P-1243, S94, V-1249, S103

Murakami A, P-1197, S86

Musonza T, P-1151, S79

Muysoms F, IP-1350, S38

Myers A, IP-1319, S19

Nabeel I, P-1035, S58

Nahabedian M, P-1214, S89

Nakeeb A, P-1199, S86

Narita M, V-1155, S101

Nassar R, P-1048, S59

Nassim O, P-1049, S60

Nathan S, FP-1173, S43

Nessel R, P-1019, S54, P-1020, S55

Neto I, P-1146, S77, V-1242, S103

Neves V, V-1041, S101

Nguyen D, IP-1310, S12

Nguyen H, P-1204, S86

Nguyen Q, P-1195, S85

Nicolo E, P-1114, S72

Niebler G, P-1164, S80, P-1174, S82

Norden S, P-1200, S86

Norrby J, FP-1093, S11

Novitisky Y, IP-1303, S8

Novitsky M, FP-1276, S41

Novitsky Y, IP-1336, S8, FP-1198, S22

123

S107 Hernia (2019) 23 (Suppl 1):S104–S109

Olasky J, IP-1287, S9

Olavarria O, FP-1260, S16, P-1254, S96, P-1255, S96, P-1257, S97

Oleynikov D, FP-1130, S14

Oliveira H, P-1113, S72, P-1140, S76

Ongos K, P-1046, S59

Onopchencko A, V-1083, S101

Oppong C, IP-1290, S36

Orenstein S, FP-1166, S45, P-1036, S58

Ortiz Gomez C, P-1180, S82, P-1205, S87, P-1208, S88,

V-1275, S103

Otahal M, FP-1202, S18

Otani T, V-1155, S101

Otero J, P-1206, S87, P-1229, S93

Ozmen J, P-1056, S61

Paasch C, P-1004, S50

Pacella S, P-1135, S75

Paige J, FP-1141, S18

Paim D, P-1270, S99

Pakula A, IP-1279, S33

Panait L, IP-1288, S34

Pantinniot P, P-1035, S58

Park H, FP-1265, S23

Parker M, P-1199, S86

Parlacoski S, FP-1226, S13

Parmar A, P-1102, S70

Patel A, P-1101, S69

Patel P, FP-1224, S29, P-1107, S70, P-1192, S85

Paul D, P-1084, S66

Pauli E, FP-1166, S45, FP-1189, S16, P-1193, S85

Pearson D, FP-1247, S44

Pedreira Junior N, P-1213, S89, P-1223, S91, P-1225, S92

Pedroso J, P-1113, S72

Pereira S, IP-1293, S34, IP-1294, S35, IP-1295, S34, FP-1237, S46,

P-1100, S69

Perez C, P-1165, S80, P-1169, S81

Perkins C, P-1102, S70

Perry K, IP-1343, S32

Petersen R, IP-1345, S32

Peterson E, P-1234, S93

Petro C, FP-1122, S41, FP-1123, S17, FP-1176, S47,

P-1021, S55, P-1190, S84, P-1263, S98, V-1126, S101,

V-1177, S102, V-1186, S27

Phillips S, P-1080, S65

Phok B, P-1094, S69

Pierce R, IP-1355, S42

Pimentel F, P-1178, S82, P-1243, S94, V-1249, S103

Pire Abaitua G, P-1006, S50, P-1007, S51, P-1008, S51, P-1009, S51,

P-1010, S52, P-1011, S52, P-1012, S52, P-1013, S53, P-1014, S53

Pisano A, FP-1246, S40

Pivetta L, P-1139, S76, P-1207, S87, V-1242, S103

Plymale M, P-1238, S93

Podolsky D, FP-1198, S22

Poulose B, IP-1304, S8, FP-1244, S10, P-1263, S98

Prabhu A, IP-1300, S8, IP-1306, S9, FP-1122, S41, FP-1123, S17,

FP-1176, S47, FP-1244, S10, P-1021, S55, P-1190, S84, P-1245, S95,

P-1263, S98, V-1126, S101, V-1177, S102, V-1186, S27

Prasad T, FP-1075, S23, FP-1124, S17, FP-1125, S26, FP-1127, S29,

P-1129, S73, P-1206, S87, P-1229, S93

Prasath V, P-1204, S86

Prebil B, P-1271, S99

Pryor A, FP-1145, S26

Qin C, FP-1163, S18, P-1073, S64, P-1117, S73, P-1159, S79,

P-1172, S81

Quezada N, P-1178, S82, P-1243, S94, V-1249, S103

Radvansky J, P-1149, S78

Raimondi S, IP-1292, S49

Rajo M, FP-1141, S18

Ramirez N, P-1165, S80, P-1169, S81

Rammohan R, P-1210, S88

Ramos Perez V, P-1008, S51, P-1010, S52, P-1011, S52, P-1014, S53

Ramshaw B, FP-1216, S17, FP-1231, S23, P-1251, S95

Rappoport J, P-1162, S80, P-1268, S99

Ratnayake S, P-1055, S60

Raul R, P-1218, S90, P-1220, S91

Ravindran P, P-1069, S63, P-1103, S70

Reed R, P-1199, S86

Rehbein P, P-1140, S76

Reid J, P-1035, S58

Reif R, P-1063, S62

Reilly M, P-1188, S84

Reinpold W, IP-1325, S25, IP-1358, S49, P-1074, S64

Rene A, P-1220, S91

Renton D, IP-1312, S12

Rhemtulla I, P-1054, S60

Ricaurte A, P-1048, S59

Richards J, FP-1191, S14, P-1240, S94

Richman J, P-1102, S70

Rimpel B, P-1079, S65

Rivera C, V-1275, S103

Rives G, P-1063, S62

Rivison M, P-1213, S89

Roberto Corsi P, P-1077, S65, P-1078, S65, P-1081, S66, P-1082, S66

Roberto Puglia C, P-1077, S65, P-1078, S65, P-1081, S66,

P-1082, S66

Roberts J, P-1256, S96

Rodrigues Armijo P, FP-1130, S14

Rodrigues H, V-1041, S101

Roll S, IP-1302, S8, FP-1137, S46, FP-1244, S10, P-1139, S76,

P-1142, S76, P-1146, S77, P-1207, S87,V-1242, S103

Roman C, P-1165, S80, P-1169, S81

Romero Funes D, P-1205, S87

Roos M, FP-1089, S40, P-1092, S68

Rosen M, FP-1122, S41, FP-1123, S17, FP-1176, S47,

FP-1244, S10, P-1021, S55, P-1190, S84, P-1245, S95,

P-1263, S98, V-1126, S101, V-1186, S27

Rosenblatt S, FP-1122, S41, FP-1123, S17, FP-1244, S10, P-1021, S55,

P-1245, S95, V-1126, S101, V-1186, S27

Rosenstock A, IP-1293, S34, IP-1294, S35, IP-1295, S34,

FP-1237, S46, P-1100, S69

Rosenthal R, P-1180, S82, P-1205, S87, P-1208, S88, P-1210, S88,

V-1275, S103

Roth J, IP-1281, S19, P-1238, S93

Rubalcava N, FP-1191, S14

Ruiz-Jasbon F, FP-1093, S11

Runyan B, P-1023, S56

Ruppert D, P-1047, S59

Saad I, IP-1333, S27

Sabido F, P-1138, S75

Sahan C, P-1090, S68

Samuel S, P-1218, S90, P-1220, S91

Sanchez Turrion V, P-1008, S51, P-1009, S51,

P-1013, S53

Sanchez-Montes I, P-1133, S71, P-1219, S91

Sanders F, P-1091, S68

Sandoval G, P-1162, S80

Sanguineti A, P-1162, S80, P-1268, S99

Santana Neto O, P-1213, S89, P-1225, S92

Santivanez Palomino J, P-1048, S59

Santoro P, P-1054, S60

Santos D, IP-1284, S33

Santos de Miranda J, P-1197, S86, P-1211, S89

Santos F, P-1213, S89, P-1223, S91

Santos H, P-1270, S99

Sarkar A, P-1103, S70

Sarmiento-Cobos M, P-1210, S88

Sarrel S, P-1062, S62

Saving A, IP-1291, S9

Sawyer M, P-1085, S66

123

Hernia (2019) 23 (Suppl 1):S104–S109 S108

Scheiber C, FP-1246, S40

Schlosser K, FP-1037, S47, FP-1097, S47,

FP-1124, S17, FP-1125, S26, FP-1127, S29, P-1128, S73,

P-1129, S73

Scholer A, FP-1237, S46

Schouten N, P-1088, S67

Schroeder A, P-1074, S64

Scott J, FP-1261, S39

Sedgwick D, IP-1290, S36

Selmani Z, P-1049, S60

Sembarski Oliveira E, P-1142, S76

Sepulveda P, P-1162, S80

Serra Lorenzo R, P-1006, S50, P-1007, S51, P-1010, S52, P-1011, S52,

P-1012, S52, P-1013, S53, P-1014, S53

Serrano Gonzalez S, P-1006, S50, P-1007, S51, P-1008, S51, P-1009, S51,

P-1013, S53

Seven C, FP-1276, S41

Sexton K, P-1063, S62

Shada A, FP-1064, S109, P-1080, S65

Shah P, P-1255, S96, P-1257, S97

Shah R, V-1275, S103

Shah S, FP-1261, S39

Shahzad N, P-1131, S74

Sharbaugh M, P-1192, S85

Sharma R, P-1148, S78

Shashkov D, P-1094, S69

Shebrain S, P-1136, S75

Shen Y, FP-1163, S18, P-1073, S64, P-1159, S79, P-1161, S80,

P-1172, S81

Shikhman A, P-1017, S54, P-1018, S54

Short C, FP-1267, S29

Shover A, FP-1265, S23

Siegal S, FP-1166, S45, P-1036, S58

Silva J, P-1162, S80, P-1268, S99

Silva R, P-1146, S77

Singh T, P-1192, S85

Smith M, P-1217, S90

Soares Gallo A, P-1077, S65, P-1078, S65, P-1081, S66, P-1082, S66

Socas J, P-1199, S86

Soriano I, P-1051, S60

Sosin M, P-1214, S89

Souza J, FP-1246, S40

Sovkova V, FP-1202, S18

Soybel D, P-1193, S85

Spaniolas K, FP-1145, S26

Ssentongo A, P-1193, S85

Ssentongo P, P-1193, S85

Stavert B, P-1056, S61

Stechemesser B, IP-1326, S25

Stetler J, P-1101, S69

Strik M, P-1004, S50

Sun S, FP-1145, S26

Svestka M, FP-1176, S47, P-1190, S84, P-1245, S95, P-1263, S98,

V-1126, S101, V-1186, S27

Symons W, P-1134, S74

Szomstein S, P-1180, S82, P-1205, S87, P-1208, S88, P-1210, S88,

V-1275, S103

Talamini M, FP-1145, S26

Talbot M, P-1069, S63, P-1103, S70

Tanaka E, P-1197, S86, P-1211, S89

Tang J, FP-1057, S40, P-1058, S61, P-1059, S61, P-1273, S100, P-1274,

S100

Tarso L, P-1113, S72

Tastaldi L, IP-1356, S42, FP-1122, S41, FP-1123, S17,

FP-1137, S46, FP-1244, S10, P-1021, S55, P-1139, S76,

P-1146, S77, P-1190, S84, P-1245, S95, V-1126, S101,

V-1177, S102, V-1242, S103, V-1186, S27

Taylor J, P-1063, S62

Tchokouani L, V-1196, S102

Tejirian T, P-1071, S63, P-1072, S63

Telem D, FP-1276, S41

Tellez L, P-1169, S81

Tenzel P, FP-1235, S42, P-1248, S95, P-1253, S95, P-1259, S97, P-1262,

S92, P-1264, S98

Thankam D, P-1188, S84

Thomas E, P-1271, S99

Thrippleton S, FP-1173, S43

Ticehurst K, FP-1093, S11

Totti Cavazzola L, IP-1357, S49

Towfigh S, IP-1317, S19, P-1148, S78

Tran-Chao H, P-1065, S62

Tubre D, P-1074, S64

Turcotte J, FP-1222, S24, FP-1226, S13, P-1228, S92

Turner B, P-1039, S58

Tuveri M, P-1114, S72

Utiyama E, P-1067, S63, P-1197, S86, P-1211, S89

van der Velde S, IP-1286, S25

van Hessen C, P-1088, S67, P-1091, S68, P-1092, S68

Varella M, P-1140, S76

Vasyluk A, FP-1171, S13, FP-1230, S42

Verleisdonk E, P-1088, S67, P-1091, S68, P-1092, S68

Vitous C, FP-1276, S41

Vitujova M, P-1149, S78

Vocetkova K, FP-1202, S18

Voigt C, P-1227, S92

Vonk J, P-1227, S92

Vujcich E, P-1055, S60

Wada N, V-1132, S27

Wang M, FP-1156, S10, FP-1158, S39

Wang N, P-1059, S61

Warren J, IP-1337, S28, FP-1224, S29, FP-1247, S44, P-1258, S97

Washburn P, P-1102, S70

Webb D, IP-1335, S28

Weimer S, V-1269, S103

Weinberg J, FP-1191, S14, P-1234, S93

Wernsing D, P-1051, S60

White B, P-1209, S88

Whitenack N, P-1227, S92

Wiessner R, IP-1290, S36

Wolkweiss B, P-1239, S94

Wood B, P-1215, S90

Wood H, FP-1176, S47

Wright G, FP-1044, S46

Xu Y, FP-1064, S109

Yamaguchi T, V-1155, S101

Yang H, P-1147, S78, P-1150, S79

Yange J, FP-1145, S26

Yheulon C, P-1101, S69

Ying-mo S, P-1152, S79

Yoo A, FP-1141, S18, FP-1267, S29

Yoo J, P-1197, S86, P-1211, S89

Youssef M, P-1207, S87

Zahiri R, FP-1222, S24, FP-1226, S13, P-1228, S92

Zakaud Dakaud A, P-1076, S64

Zaman J, P-1192, S85

Zanirati T, P-1239, S94

Zatir S, P-1049, S60

Zhu C, FP-1145, S26

Zhu L, FP-1057, S40, P-1058, S61, P-1059, S61, P-1273, S100,

P-1274, S100

Zhu Y, FP-1156, S10, FP-1158, S39

Zilberstein B, P-1207, S87

Zuardi A, P-1197, S86, P-1211, S89

Zumba O, IP-1293, S34, IP-1294, S35, IP-1295, S34, FP-1237, S46

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S109 Hernia (2019) 23 (Suppl 1):S104–S109

2019 ahs annual meeting - americanherniasociety.org · 8:15–8:30 introduction of the americas...

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